Provider Demographics
NPI:1659639177
Name:POTTS, KERRY
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-0925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 NE VILLAGE ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-3827
Practice Address - Country:US
Practice Address - Phone:360-356-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist