Basic Information
| Provider Information | |||||||||
| NPI: | 1477021657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | JANETTE | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LABURN | ||||||||
| OtherFirstName: | JANETTE | ||||||||
| OtherMiddleName: | MAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS LLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23400 ALLOR ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480821147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869940772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1660 FORT ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343044159 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | 6301007137 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.