Provider Demographics
NPI:1548669039
Name:POTTER, ROBERT (LASAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12443
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-2443
Mailing Address - Country:US
Mailing Address - Phone:928-380-1526
Mailing Address - Fax:
Practice Address - Street 1:1630 SHOUP ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1343
Practice Address - Country:US
Practice Address - Phone:928-277-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)