Provider Demographics
NPI:1942930276
Name:POTTER, ISSAURA MARIBEL (LPC)
Entity Type:Individual
Prefix:
First Name:ISSAURA
Middle Name:MARIBEL
Last Name:POTTER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 S ELDERBERRY PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4492
Mailing Address - Country:US
Mailing Address - Phone:208-519-0901
Mailing Address - Fax:
Practice Address - Street 1:6003 W OVERLAND RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3075
Practice Address - Country:US
Practice Address - Phone:208-204-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8841101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health