Provider Demographics
NPI:1225120884
Name:POTTS, KENNETH CHARLES (LCPC, LMFT, LSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHARLES
Last Name:POTTS
Suffix:
Gender:M
Credentials:LCPC, LMFT, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 BAY SCOTT CIR STE 109
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-1130
Mailing Address - Country:US
Mailing Address - Phone:630-357-2456
Mailing Address - Fax:630-357-2482
Practice Address - Street 1:1819 BAY SCOTT CIR STE 109
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-1130
Practice Address - Country:US
Practice Address - Phone:630-357-2456
Practice Address - Fax:630-357-2482
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist