Provider Demographics
NPI:1700184165
Name:POTTER, SUSAN J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:POTTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 CONRAD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-5276
Mailing Address - Country:US
Mailing Address - Phone:509-453-7789
Mailing Address - Fax:
Practice Address - Street 1:710 N 39TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6342
Practice Address - Country:US
Practice Address - Phone:509-248-4102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60040990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant