Provider Demographics
NPI:1285982686
Name:POTTER, MATTHEW O'NEIL
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:O'NEIL
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 SYLVAN SAND
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099
Mailing Address - Country:US
Mailing Address - Phone:405-206-4006
Mailing Address - Fax:
Practice Address - Street 1:1317 SYLVAN SAND
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-3161
Practice Address - Country:US
Practice Address - Phone:405-206-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225C00000X225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor