Provider Demographics
NPI:1306534789
Name:POTTER, MICHAEL PATRICK (MASTERS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:POTTER
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:119 W TORRANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5741 LAS VIRGENES RD
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1272
Practice Address - Country:US
Practice Address - Phone:818-712-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20-111005106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician