Provider Demographics
NPI:1205492758
Name:POTTER, KRISTIE (LMFT, LPCC)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CROW CANYON CT STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1641
Mailing Address - Country:US
Mailing Address - Phone:925-587-6617
Mailing Address - Fax:
Practice Address - Street 1:1 CROW CANYON CT STE 110
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1641
Practice Address - Country:US
Practice Address - Phone:925-587-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43455101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health