Provider Demographics
NPI:1336643899
Name:POTTER, AMARA (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMARA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 W ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5424
Mailing Address - Country:US
Mailing Address - Phone:845-240-0811
Mailing Address - Fax:
Practice Address - Street 1:2224 W ALTA VISTA RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5424
Practice Address - Country:US
Practice Address - Phone:845-240-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7824171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor