Provider Demographics
NPI:1063491413
Name:POTTER, ANN ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:ELIZABETH
Last Name:POTTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12822 AUGUSTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144
Mailing Address - Country:US
Mailing Address - Phone:402-403-0190
Mailing Address - Fax:402-932-4121
Practice Address - Street 1:12822 AUGUSTA AVENUE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-403-0190
Practice Address - Fax:402-932-4121
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE279103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE08382OtherBLUE CROSS BLUE SHIELD
NE08382OtherBC/BS
600509097OtherMEGELLAN
NE08382OtherBC/BS
R29978Medicare UPIN