Provider Demographics
NPI:1689334153
Name:POTTER, RICKENDRA BROOKE (OTR/L)
Entity Type:Individual
Prefix:
First Name:RICKENDRA
Middle Name:BROOKE
Last Name:POTTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 OLD BELL HIGH RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-8239
Mailing Address - Country:US
Mailing Address - Phone:606-499-7730
Mailing Address - Fax:
Practice Address - Street 1:39 FERNDALE APARTMENTS RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-8578
Practice Address - Country:US
Practice Address - Phone:606-337-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7079225X00000X
KY274257225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist