Provider Demographics
NPI:1134345358
Name:POTTER, WENDY (MED, LMHC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 CALLE DEL MAR
Mailing Address - Street 2:
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7602
Mailing Address - Country:US
Mailing Address - Phone:321-768-6800
Mailing Address - Fax:
Practice Address - Street 1:1800 PENN ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2625
Practice Address - Country:US
Practice Address - Phone:321-768-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0004359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ8162OtherBCBS