Provider Demographics
NPI:1871706481
Name:POTTER, BRENT
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2865 RAWHIDE DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7819
Mailing Address - Country:US
Mailing Address - Phone:928-692-9813
Mailing Address - Fax:928-692-1507
Practice Address - Street 1:4182 N BANK ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2715
Practice Address - Country:US
Practice Address - Phone:928-692-9813
Practice Address - Fax:928-692-1507
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ961575Medicaid