Provider Demographics
NPI:1487906665
Name:POTTER, MICHAEL DAVID (LPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:POTTER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1703 FOGGY GLEN CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-1541
Mailing Address - Country:US
Mailing Address - Phone:512-263-3715
Mailing Address - Fax:
Practice Address - Street 1:3513 SW H K DODGEN LOOP
Practice Address - Street 2:SUITE NUMBER 106
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-8009
Practice Address - Country:US
Practice Address - Phone:254-778-4673
Practice Address - Fax:254-526-4853
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12553101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health