Provider Demographics
NPI:1346639903
Name:POTTER, MARTHA (MS)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-1105
Mailing Address - Country:US
Mailing Address - Phone:906-458-4174
Mailing Address - Fax:
Practice Address - Street 1:308 CLEVELAND AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-1845
Practice Address - Country:US
Practice Address - Phone:906-458-4174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL499514101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor