Provider Demographics
NPI:1457670051
Name:POTTER, PHILLIP ADAM (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ADAM
Last Name:POTTER
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5469
Mailing Address - Country:US
Mailing Address - Phone:720-772-7334
Mailing Address - Fax:
Practice Address - Street 1:5412 IDYLWILD TRL # 100
Practice Address - Street 2:SUITE 107
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3523
Practice Address - Country:US
Practice Address - Phone:720-772-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst