Provider Demographics
NPI:1639506207
Name:POTTERS HOUSE CHURCH
Entity Type:Organization
Organization Name:POTTERS HOUSE CHURCH
Other - Org Name:MOLDING MINDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-896-5026
Mailing Address - Street 1:PO BOX 11303
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39283-1303
Mailing Address - Country:US
Mailing Address - Phone:601-982-9692
Mailing Address - Fax:601-952-0548
Practice Address - Street 1:5913 FLORAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2413
Practice Address - Country:US
Practice Address - Phone:601-982-9692
Practice Address - Fax:601-952-0548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08930021251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health