Provider Demographics
NPI:1649211608
Name:POTTER, ELLIS BRIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:BRIAN
Last Name:POTTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18846 E SARATOGA CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4932
Mailing Address - Country:US
Mailing Address - Phone:303-693-3630
Mailing Address - Fax:303-627-1573
Practice Address - Street 1:18846 E SARATOGA CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-4932
Practice Address - Country:US
Practice Address - Phone:303-693-3630
Practice Address - Fax:303-627-1573
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical