Provider Demographics
NPI:1609016070
Name:POTTER, CAROL (MFC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3342 BARBYDELL DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4810
Mailing Address - Country:US
Mailing Address - Phone:310-636-9628
Mailing Address - Fax:310-836-0378
Practice Address - Street 1:9696 CULVER BLVD.
Practice Address - Street 2:SUITE 303
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2759
Practice Address - Country:US
Practice Address - Phone:310-636-9628
Practice Address - Fax:310-836-0378
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37766106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist