Provider Demographics
NPI:1336654953
Name:POTTER, AMANDA CLAIRE (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CLAIRE
Last Name:POTTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 168TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-4536
Mailing Address - Country:US
Mailing Address - Phone:509-961-3163
Mailing Address - Fax:
Practice Address - Street 1:11212 NE 112TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4520
Practice Address - Country:US
Practice Address - Phone:425-936-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist