Provider Demographics
NPI:1841924297
Name:POTTER, FALLON RAE
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:RAE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111-9701
Mailing Address - Country:US
Mailing Address - Phone:716-796-3416
Mailing Address - Fax:716-337-2723
Practice Address - Street 1:2101 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:NORTH COLLINS
Practice Address - State:NY
Practice Address - Zip Code:14111-9701
Practice Address - Country:US
Practice Address - Phone:716-796-3416
Practice Address - Fax:716-337-2723
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor