Provider Demographics
NPI:1497039705
Name:DAVIS, POTA JOHN
Entity Type:Individual
Prefix:
First Name:POTA
Middle Name:JOHN
Last Name:DAVIS
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 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-265-2000
Mailing Address - Fax:315-265-2048
Practice Address - Street 1:29 LEROY ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-265-2000
Practice Address - Fax:315-265-2048
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005272-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist