Provider Demographics
NPI:1235445529
Name:POTTER, REBECCA LYNN (BCABA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:POTTER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 CORDIAL ALY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-3210
Mailing Address - Country:US
Mailing Address - Phone:843-425-5350
Mailing Address - Fax:
Practice Address - Street 1:4341 CORDIAL ALY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-3210
Practice Address - Country:US
Practice Address - Phone:843-425-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-13-0472106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst