Provider Demographics
NPI:1417599416
Name:POTTER, MAEANNA LEE
Entity type:Individual
Prefix:
First Name:MAEANNA
Middle Name:LEE
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 1:12875 CUMMING HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4885
Mailing Address - Country:US
Mailing Address - Phone:770-240-0163
Mailing Address - Fax:
Practice Address - Street 1:12875 CUMMING HWY STE 104
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-4885
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician