Provider Demographics
NPI:1154434413
Name:POTTS, RANDOLPH GERALD (PHD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:GERALD
Last Name:POTTS
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 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:901-478-0954
Mailing Address - Fax:901-478-0951
Practice Address - Street 1:1325 EASTMORELAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3507
Practice Address - Country:US
Practice Address - Phone:901-516-8785
Practice Address - Fax:901-516-8358
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002490103T00000X
TN2490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3980543Medicare ID - Type Unspecified