Provider Demographics
NPI:1093298101
Name:POTTS, MEGAN E
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:POTTS
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 1:301 N SECOND STREET
Mailing Address - Street 2:PO BOX 318
Mailing Address - City:ASHKUM
Mailing Address - State:ID
Mailing Address - Zip Code:60911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1390 S CRESCENT ST
Practice Address - Street 2:
Practice Address - City:GILMAN
Practice Address - State:IL
Practice Address - Zip Code:60938-6129
Practice Address - Country:US
Practice Address - Phone:815-265-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012350225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist