Provider Demographics
NPI:1578955704
Name:POTTER, DREW ALEXANDER (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:ALEXANDER
Last Name:POTTER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 CROMWELL CT
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3915
Mailing Address - Country:US
Mailing Address - Phone:815-742-4392
Mailing Address - Fax:
Practice Address - Street 1:4530 CROMWELL CT
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3915
Practice Address - Country:US
Practice Address - Phone:815-742-4392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0041142255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer