Doctor Name: | JEREMY POTTER |
NPI Number: | 1023242534 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LICSW |
License Number: | 114179 |
Business Practice Address: | 340 Maple St 4th Floor Marlborough, MA - 017523200 |
Business Phone Number: | 5084859300 |
Business Fax Number: | |
Mailing Address: | 17 Saxon Rd, WORCESTER |
State: | MA |
Postal Code: | 016021521 |
Phone Number: | 5083956857 |
Fax Number: | |
NPI Enumeration Date: | 05/12/2009 |
NPI Last Update Date: | 05/12/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 114179 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |