Provider Demographics
NPI:1881196434
Name:POTTER, REGINA JOANNE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:JOANNE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 CUBA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5727
Mailing Address - Country:US
Mailing Address - Phone:575-437-2453
Mailing Address - Fax:575-443-1504
Practice Address - Street 1:1301 CUBA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5727
Practice Address - Country:US
Practice Address - Phone:575-437-2453
Practice Address - Fax:575-443-1504
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0194611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health