Provider Demographics
NPI:1093322232
Name:POTTS, MISTY (CDCA171568)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:POTTS
Suffix:
Gender:F
Credentials:CDCA171568
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 ENXING AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2010
Mailing Address - Country:US
Mailing Address - Phone:937-867-9733
Mailing Address - Fax:
Practice Address - Street 1:436 ENXING AVE
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2010
Practice Address - Country:US
Practice Address - Phone:937-867-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA171568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)