Provider Demographics
NPI:1700447331
Name:POTTER, KYLE PERRY (BA)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:PERRY
Last Name:POTTER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:104 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3212
Mailing Address - Country:US
Mailing Address - Phone:401-499-8286
Mailing Address - Fax:
Practice Address - Street 1:110 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2423
Practice Address - Country:US
Practice Address - Phone:401-300-5757
Practice Address - Fax:401-300-5656
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)