Provider Demographics
NPI:1275363954
Name:POTTER, MARLENA JEAN
Entity type:Individual
Prefix:
First Name:MARLENA
Middle Name:JEAN
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 1:2222 2ND ST STE 10
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4555
Mailing Address - Country:US
Mailing Address - Phone:925-667-1492
Mailing Address - Fax:
Practice Address - Street 1:2222 2ND ST STE 10
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4555
Practice Address - Country:US
Practice Address - Phone:925-667-1492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141243106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist