Provider Demographics
NPI:1578122826
Name:POTTER, PAGAN MARIE (MHP)
Entity Type:Individual
Prefix:
First Name:PAGAN
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2114
Mailing Address - Country:US
Mailing Address - Phone:618-889-3329
Mailing Address - Fax:
Practice Address - Street 1:218 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2114
Practice Address - Country:US
Practice Address - Phone:618-889-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health