Provider Demographics
NPI:1578951794
Name:POTTER, SUSAN (PPC-913)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:PPC-913
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CASE MANAGER
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-0376
Mailing Address - Country:US
Mailing Address - Phone:307-885-9883
Mailing Address - Fax:307-885-5206
Practice Address - Street 1:389 ADAMS ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-0376
Practice Address - Country:US
Practice Address - Phone:307-885-9883
Practice Address - Fax:307-885-5206
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
WYPPC-913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator