Provider Demographics
NPI:1417530718
Name:POTTER, BETH SUZANNE
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:SUZANNE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOOSUP
Mailing Address - State:CT
Mailing Address - Zip Code:06354-1524
Mailing Address - Country:US
Mailing Address - Phone:570-578-5787
Mailing Address - Fax:
Practice Address - Street 1:144 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3239
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst