Provider Demographics
NPI:1568649036
Name:POTTER, DALE JAMES (MA)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:JAMES
Last Name:POTTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6379 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9566
Mailing Address - Country:US
Mailing Address - Phone:989-777-4357
Mailing Address - Fax:989-777-7257
Practice Address - Street 1:6379 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9566
Practice Address - Country:US
Practice Address - Phone:989-777-4357
Practice Address - Fax:989-777-7257
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010668104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker