Provider Demographics
NPI:1013024686
Name:POTTER, LIDU IVETTE (OT)
Entity Type:Individual
Prefix:
First Name:LIDU
Middle Name:IVETTE
Last Name:POTTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 ALT 19 STE A
Mailing Address - Street 2:
Mailing Address - City:PALM
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5363
Mailing Address - Country:US
Mailing Address - Phone:727-773-2687
Mailing Address - Fax:
Practice Address - Street 1:971 VIRGINIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5235
Practice Address - Country:US
Practice Address - Phone:727-773-2687
Practice Address - Fax:727-773-2742
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10194225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887471900Medicaid