Provider Demographics
NPI:1851806699
Name:POTTER, NICHOLAS MICHAEL (MA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:POTTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9542
Mailing Address - Country:US
Mailing Address - Phone:616-773-2908
Mailing Address - Fax:616-532-3046
Practice Address - Street 1:1055 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49509-9542
Practice Address - Country:US
Practice Address - Phone:616-773-2908
Practice Address - Fax:616-532-3046
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-17-44099106S00000X
MI6451023025101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician