1245329077 NPI number — MR. CARL LEWIS POTTER III LCSW

Table of content: MR. CARL LEWIS POTTER III LCSW (NPI 1245329077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245329077 NPI number — MR. CARL LEWIS POTTER III LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTER
Provider First Name:
CARL
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245329077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 N SIXTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEBANE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27302-2207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-304-5614
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5003 SOUTHPARK DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27713-9414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-493-6329
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C003834 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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