Provider Demographics
NPI:1891243903
Name:POTTS, TRACEY JR
Entity Type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:
Last Name:POTTS
Suffix:JR
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 1:1225 BELL ST APT 121
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3587
Mailing Address - Country:US
Mailing Address - Phone:209-261-4338
Mailing Address - Fax:
Practice Address - Street 1:1225 BELL ST APT 121
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3587
Practice Address - Country:US
Practice Address - Phone:209-261-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-18
Last Update Date:2016-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-15-11020103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst