Provider Demographics
NPI:1457361735
Name:POTTS, TIA ROSE (BS OF PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:ROSE
Last Name:POTTS
Suffix:
Gender:F
Credentials:BS OF PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20075 NORTHVILLE PLACE DR APT 3106
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2961
Mailing Address - Country:US
Mailing Address - Phone:248-773-9900
Mailing Address - Fax:
Practice Address - Street 1:1400 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2651
Practice Address - Country:US
Practice Address - Phone:248-547-2223
Practice Address - Fax:248-547-2226
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI631090Medicaid