Provider Demographics
NPI:1578059911
Name:POTTERTON, KIERAN MICHAEL
Entity Type:Individual
Prefix:MR
First Name:KIERAN
Middle Name:MICHAEL
Last Name:POTTERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 GRASSY POINTE LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-3698
Mailing Address - Country:US
Mailing Address - Phone:865-313-6785
Mailing Address - Fax:865-315-7014
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4729
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLBA0000000188103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-30560OtherBOARD CERTIFIED BEHAVIOR ANALYST
TNLBA0000000188OtherLICENSED BEHAVIOR ANALYST