Provider Demographics
NPI:1639534480
Name:POTTER, MICHAEL HENRY (MLADC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HENRY
Last Name:POTTER
Suffix:
Gender:M
Credentials:MLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 US ROUTE 10
Mailing Address - Street 2:
Mailing Address - City:LEMPSTER
Mailing Address - State:NH
Mailing Address - Zip Code:03605-3302
Mailing Address - Country:US
Mailing Address - Phone:603-863-7948
Mailing Address - Fax:603-355-0159
Practice Address - Street 1:33 WEST ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3361
Practice Address - Country:US
Practice Address - Phone:603-355-0157
Practice Address - Fax:603-355-0159
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0179101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)