Provider Demographics
NPI:1790539112
Name:POTTER, LEA (CASAC)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4528
Mailing Address - Country:US
Mailing Address - Phone:518-952-8368
Mailing Address - Fax:
Practice Address - Street 1:3584 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1006
Practice Address - Country:US
Practice Address - Phone:718-653-1537
Practice Address - Fax:718-228-6993
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23724101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)