Provider Demographics
NPI:1972110575
Name:POTTS, DEREK B (BCBA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:B
Last Name:POTTS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 YALE ST
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3281
Mailing Address - Country:US
Mailing Address - Phone:607-624-1161
Mailing Address - Fax:
Practice Address - Street 1:203 S ELMER AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2019
Practice Address - Country:US
Practice Address - Phone:607-760-9520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-19-36291103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst