Provider Demographics
NPI:1003073099
Name:POTTER, CAROL (MA, BCBA, LBA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HUNT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5605
Mailing Address - Country:US
Mailing Address - Phone:248-537-2516
Mailing Address - Fax:
Practice Address - Street 1:2200 HUNT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-5605
Practice Address - Country:US
Practice Address - Phone:248-537-2516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841905551OtherGROUP NPI
MI1003073099Medicaid