Provider Demographics
NPI:1013624287
Name:POTTS, MATTHEW (COTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 WAKEFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-2604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:787 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1111
Practice Address - Country:US
Practice Address - Phone:260-463-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001213A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant