Provider Demographics
NPI:1275746950
Name:POTTER, KIRBY IAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KIRBY
Middle Name:IAN
Last Name:POTTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 HERITAGE LN
Mailing Address - Street 2:SUITE B - 103
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8552
Mailing Address - Country:US
Mailing Address - Phone:801-525-6975
Mailing Address - Fax:801-525-6988
Practice Address - Street 1:1747 HERITAGE LN
Practice Address - Street 2:SUITE B - 103
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8552
Practice Address - Country:US
Practice Address - Phone:801-525-6975
Practice Address - Fax:801-525-6988
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113382-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical