Provider Demographics
NPI:1366229544
Name:POTTS, STASIE
Entity type:Individual
Prefix:
First Name:STASIE
Middle Name:
Last Name:POTTS
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 1:19700 HICKORY TWIG WAY
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-6265
Mailing Address - Country:US
Mailing Address - Phone:346-328-9964
Mailing Address - Fax:
Practice Address - Street 1:19700 HICKORY TWIG WAY SPRING TEXAS
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388
Practice Address - Country:US
Practice Address - Phone:346-328-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111111111111QOtherWORK INSURANCE