Provider Demographics
NPI:1215210448
Name:POTTER, JOAN MARIE
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:MARIE
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1400 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1786
Mailing Address - Country:US
Mailing Address - Phone:806-414-9680
Mailing Address - Fax:806-354-5591
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-414-9680
Practice Address - Fax:806-354-5591
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1076602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX315166402Medicaid
NM98825364Medicaid
OK200449730 AMedicaid
TX315166401Medicaid
NM98825364Medicaid