Provider Demographics
NPI:1275043572
Name:POTTER FAILE, ERIN MARJORIE (LPMT, MT-BC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MARJORIE
Last Name:POTTER FAILE
Suffix:
Gender:F
Credentials:LPMT, MT-BC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MARJORIE
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT-BC
Mailing Address - Street 1:12060 ETRIS RD # 200
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1463
Mailing Address - Country:US
Mailing Address - Phone:678-701-1203
Mailing Address - Fax:
Practice Address - Street 1:12060 ETRIS RD # 200
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1463
Practice Address - Country:US
Practice Address - Phone:678-701-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMUT000127225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist