Provider Demographics
NPI:1225513005
Name:POTTER, PAULETTE JENEVIEVE (SLP)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:JENEVIEVE
Last Name:POTTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WEST ORANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ORANGE GROVE
Mailing Address - State:TX
Mailing Address - Zip Code:78372
Mailing Address - Country:US
Mailing Address - Phone:830-285-4645
Mailing Address - Fax:830-285-4645
Practice Address - Street 1:606 COYOTE TRL
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4004
Practice Address - Country:US
Practice Address - Phone:830-285-4645
Practice Address - Fax:830-285-4645
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist