Provider Demographics
NPI:1326838665
Name:POTTER, JUSTIN (LICSW)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:POTTER
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E 78TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1402
Mailing Address - Country:US
Mailing Address - Phone:952-854-5034
Mailing Address - Fax:
Practice Address - Street 1:1101 E 78TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1402
Practice Address - Country:US
Practice Address - Phone:952-854-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN245101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical