Provider Demographics
NPI:1558684902
Name:POTTS, BREEZE CAROLINE SHAW (MA)
Entity Type:Individual
Prefix:
First Name:BREEZE
Middle Name:CAROLINE SHAW
Last Name:POTTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-4059
Mailing Address - Country:US
Mailing Address - Phone:360-714-9648
Mailing Address - Fax:
Practice Address - Street 1:1101 HARRIS AVE STE 22
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7062
Practice Address - Country:US
Practice Address - Phone:360-201-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00050770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health