Provider Demographics
NPI:1356447569
Name:POTTS, MICHAEL DAN (M DIV)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAN
Last Name:POTTS
Suffix:
Gender:M
Credentials:M DIV
Other - Prefix:
Other - First Name:MICKEY
Other - Middle Name:
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2500 SOUTH BROADWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-340-5113
Mailing Address - Fax:405-340-8965
Practice Address - Street 1:2500 SOUTH BROADWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-340-5113
Practice Address - Fax:405-340-8965
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK462101YP2500X
OK064106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist