Basic Information
| Provider Information | |||||||||
| NPI: | 1164016523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTEET | ||||||||
| FirstName: | MANSON | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 RIDGEWAY CT | ||||||||
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| City: | FERDINAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475329572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159175301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1712 LELAND DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475424754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126834090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2021 | ||||||||
| LastUpdateDate: | 03/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06006025A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.