Provider Demographics
NPI:1609985332
Name:POTTER, PAUL DENNIS (MAC, MSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DENNIS
Last Name:POTTER
Suffix:
Gender:M
Credentials:MAC, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 SW 5TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4976
Mailing Address - Country:US
Mailing Address - Phone:503-963-7756
Mailing Address - Fax:503-963-7711
Practice Address - Street 1:2130 SW 5TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4976
Practice Address - Country:US
Practice Address - Phone:503-963-7756
Practice Address - Fax:503-963-7711
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR86-01-03101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)