Provider Demographics
NPI:1083935654
Name:POTTER, SANDRA L
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9706 CARITA CT
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-2103
Mailing Address - Country:US
Mailing Address - Phone:619-448-7775
Mailing Address - Fax:
Practice Address - Street 1:835 3RD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-427-4661
Practice Address - Fax:619-426-7849
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083935654OtherPEER SPECIALIST