Provider Demographics
NPI:1104904762
Name:POTTS, JUDITH E (MA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:E
Last Name:POTTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 SE 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7617
Mailing Address - Country:US
Mailing Address - Phone:503-777-5925
Mailing Address - Fax:
Practice Address - Street 1:7507 NE 51ST ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6007
Practice Address - Country:US
Practice Address - Phone:360-906-1190
Practice Address - Fax:360-906-1193
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004692101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health