MEDICARE: TOVAH POTTER CADC I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	11-12-57	OR

General Provider Information

NPI Number	:	1659719896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOVAH POTTER CADC I

Provider Business Mailing Address
First Line	:	3680 MIDWAY DR
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1466
Country	:	US
Telephone Number	:	541-523-4049
Fax Number	:	541-523-4062

Provider Business Practice Location Address
First Line	:	3680 MIDWAY DR
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1466
Country	:	US
Telephone Number	:	541-523-4049
Fax Number	:	541-523-4062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	06/10/2013

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