Provider Demographics
NPI:1306174115
Name:POTTERS PLACE, LLC
Entity type:Organization
Organization Name:POTTERS PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARDELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-848-0629
Mailing Address - Street 1:8629 W ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3519
Mailing Address - Country:US
Mailing Address - Phone:623-848-0629
Mailing Address - Fax:623-873-6127
Practice Address - Street 1:8629 W ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3519
Practice Address - Country:US
Practice Address - Phone:623-848-0629
Practice Address - Fax:623-873-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3284251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health