Provider Demographics
NPI:1740266576
Name:POTTERAT, ERIC G (PHD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:G
Last Name:POTTERAT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11865 ARBORLAKE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2608
Mailing Address - Country:US
Mailing Address - Phone:619-437-3652
Mailing Address - Fax:
Practice Address - Street 1:NAVAL SPECIAL WARFARE CENTER
Practice Address - Street 2:2446 TRIDENT WAY
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5494
Practice Address - Country:US
Practice Address - Phone:619-437-3652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical