Provider Demographics
NPI:1790404150
Name:POTTER, MELINDA PEARL (MS, PLMHP)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:PEARL
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS, PLMHP
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:PEARL
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:NE
Mailing Address - Zip Code:69155-0161
Mailing Address - Country:US
Mailing Address - Phone:435-503-0424
Mailing Address - Fax:
Practice Address - Street 1:103 E 10TH ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-1442
Practice Address - Country:US
Practice Address - Phone:308-284-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE13258OtherPROVISIONAL MENTAL HEALTH PRACTITIONER