Provider Demographics
NPI:1962795526
Name:POTOSKI, THOMAS M (LCPC)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:POTOSKI
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-6870
Mailing Address - Country:US
Mailing Address - Phone:815-662-7757
Mailing Address - Fax:815-928-9335
Practice Address - Street 1:4 DUNCAN DR SUITE C
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1083
Practice Address - Country:US
Practice Address - Phone:815-662-7757
Practice Address - Fax:815-928-9335
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-001413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional