Provider Demographics
NPI:1053827055
Name:POTTER, JAMES J (RBT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:POTTER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1225 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-5517
Mailing Address - Country:US
Mailing Address - Phone:831-915-8659
Mailing Address - Fax:
Practice Address - Street 1:3180 IMJIN RD STE 149
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-5111
Practice Address - Country:US
Practice Address - Phone:831-786-0600
Practice Address - Fax:831-786-0600
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-15-01139106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician