Provider Demographics
NPI:1548866007
Name:POTTER, KEELA NOELLE
Entity type:Individual
Prefix:
First Name:KEELA
Middle Name:NOELLE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SOMERSET PL
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7140
Mailing Address - Country:US
Mailing Address - Phone:602-670-2376
Mailing Address - Fax:
Practice Address - Street 1:500 W FOSTER RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-3620
Practice Address - Country:US
Practice Address - Phone:805-934-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker