Provider Demographics
NPI:1639564149
Name:POTTER, MARGIE ETHEL (CICA00860419)
Entity Type:Individual
Prefix:MRS
First Name:MARGIE
Middle Name:ETHEL
Last Name:POTTER
Suffix:
Gender:F
Credentials:CICA00860419
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10877 CONDUCTOR BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-9688
Mailing Address - Country:US
Mailing Address - Phone:209-223-6412
Mailing Address - Fax:
Practice Address - Street 1:10877 CONDUCTOR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-9688
Practice Address - Country:US
Practice Address - Phone:209-223-6412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CACICA00860419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program