Basic Information
| Provider Information | |||||||||
| NPI: | 1083935654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9706 CARITA CT | ||||||||
| Address2: | |||||||||
| City: | SANTEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920712103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194487775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 835 3RD AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919111352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194274661 | ||||||||
| FaxNumber: | 6194267849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2010 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1083935654 | 01 | CA | PEER SPECIALIST | OTHER |