Basic Information
| Provider Information | |||||||||
| NPI: | 1013624287 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | POTTS | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 WAKEFIELD CIR | ||||||||
| Address2: | |||||||||
| City: | KENDALLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467552604 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 787 N DETROIT ST | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467611111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604632172 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32001213A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.