Provider Demographics
NPI:1659442093
Name:POTTS, NICOLE RENAE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENAE
Last Name:POTTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 DUNWOODY DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8889
Mailing Address - Country:US
Mailing Address - Phone:870-930-6372
Mailing Address - Fax:870-930-9336
Practice Address - Street 1:151 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5828
Practice Address - Country:US
Practice Address - Phone:870-932-0090
Practice Address - Fax:870-930-9336
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10127-M104100000X
ARSP#1761235Z00000X
AR10127-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142215721Medicaid
ARSP 5W442OtherBCBS