Basic Information
| Provider Information | |||||||||
| NPI: | 1750803987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTS | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550769 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772550769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | 7136869413 | ||||||||
| Practice Location | |||||||||
| Address1: | 7787 PINEMONT DR STE B | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770406216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | 7136869413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2017 | ||||||||
| LastUpdateDate: | 07/10/2017 | ||||||||
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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 | 1041C0700X | 57760 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 57760 | 01 | TX | LICENSE | OTHER |