Provider Demographics
NPI:1659473106
Name:POTTER, TRUDY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 NEWGATE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4696
Mailing Address - Country:US
Mailing Address - Phone:208-552-9971
Mailing Address - Fax:
Practice Address - Street 1:1257 NEWGATE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4696
Practice Address - Country:US
Practice Address - Phone:208-552-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID248225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant