Provider Demographics
NPI:1740610278
Name:POTTS, BRIAN (PSYD, CSAC, BCBA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:PSYD, CSAC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 LINCOLN STREET, HAHNEMANN FAMILY HEALTH CENTER
Mailing Address - Street 2:UMASS MEMORIAL MEDICAL CENTER
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1736
Mailing Address - Country:US
Mailing Address - Phone:508-334-8830
Mailing Address - Fax:508-334-8810
Practice Address - Street 1:4029 DEAN MARTIN DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4138
Practice Address - Country:US
Practice Address - Phone:702-848-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0858103TC0700X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1740610278Medicaid