Provider Demographics
NPI:1477297208
Name:POTTER, KYLE (PHD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 DEVONSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4736
Mailing Address - Country:US
Mailing Address - Phone:315-529-7748
Mailing Address - Fax:
Practice Address - Street 1:716 DEVONSHIRE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4736
Practice Address - Country:US
Practice Address - Phone:315-529-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06805103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist