Provider Demographics
NPI:1225147960
Name:THE POTTER'S HOUSE SUBSTANCE ABUSE CENTER
Entity Type:Organization
Organization Name:THE POTTER'S HOUSE SUBSTANCE ABUSE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEENA
Authorized Official - Middle Name:ROSETTE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-254-9701
Mailing Address - Street 1:1717 W NORTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5400
Mailing Address - Country:US
Mailing Address - Phone:602-254-9701
Mailing Address - Fax:602-252-0830
Practice Address - Street 1:1717 W NORTHERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5400
Practice Address - Country:US
Practice Address - Phone:602-254-9701
Practice Address - Fax:602-252-0830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 251S00000X
AZBH3520251S00000X
AZLISAC-10784261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1225147960OtherNPI
AZ004477Medicaid