Provider Demographics
NPI:1215075700
Name:POTTER, THERESA (ACSW LCSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:ACSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7202 NORTH SHADELAND AVENUE
Mailing Address - Street 2:SUITE 127
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250
Mailing Address - Country:US
Mailing Address - Phone:317-849-9646
Mailing Address - Fax:317-849-9651
Practice Address - Street 1:7202 NORTH SHADELAND AVENUE
Practice Address - Street 2:SUITE 127
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-849-9646
Practice Address - Fax:317-849-9651
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000816A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker