Provider Demographics
NPI:1861819062
Name:POTTER, DANIEL ROBERTSON
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERTSON
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 HATCH RUN RD STE 4
Mailing Address - Street 2:
Mailing Address - City:NORTH WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-5249
Mailing Address - Country:US
Mailing Address - Phone:148-176-8088
Mailing Address - Fax:
Practice Address - Street 1:60 HATCH RUN RD STE 4
Practice Address - Street 2:
Practice Address - City:NORTH WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5249
Practice Address - Country:US
Practice Address - Phone:148-176-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
PAPC017055101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator