Provider Demographics
NPI:1508294166
Name:POTTER, PHYLLIS ANN (MS, LPC, NCC, RPT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANN
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS, LPC, NCC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1734
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-1734
Mailing Address - Country:US
Mailing Address - Phone:910-299-0848
Mailing Address - Fax:910-299-0850
Practice Address - Street 1:930 CAMBRIDGE ST
Practice Address - Street 2:SUITE 109
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-9625
Practice Address - Country:US
Practice Address - Phone:910-484-2202
Practice Address - Fax:910-484-2203
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health