Provider Demographics
NPI:1164053393
Name:POTTER, CHRISTY MICHELLE (APCC)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:MICHELLE
Last Name:POTTER
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22445 ALESSANDRO BLVD STE 113-114
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8358
Mailing Address - Country:US
Mailing Address - Phone:951-924-9791
Mailing Address - Fax:
Practice Address - Street 1:22445 ALESSANDRO BLVD STE 113-114
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8358
Practice Address - Country:US
Practice Address - Phone:951-924-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7390101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98399251C63319OtherHMO