Provider Demographics
NPI:1407946700
Name:POTTER, VICKIE LYNN (MS, LP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-9470
Mailing Address - Country:US
Mailing Address - Phone:320-564-2488
Mailing Address - Fax:
Practice Address - Street 1:290 9TH AVE
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241-1439
Practice Address - Country:US
Practice Address - Phone:320-564-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2895103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2897227OtherTAX NUMBER
MNL.P 2895OtherL.P. NUMBER
MN114832OtherU CARE
MN9H516POOtherBLUE CROSS BLUE SHIELD
MNP51552OtherARAZ CODE