Provider Demographics
NPI:1639294903
Name:POTTER, CARLA C (MSSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:C
Last Name:POTTER
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 RIDGEBURY RD
Mailing Address - Street 2:
Mailing Address - City:SLATE HILL
Mailing Address - State:NY
Mailing Address - Zip Code:10973-4310
Mailing Address - Country:US
Mailing Address - Phone:845-355-1092
Mailing Address - Fax:845-355-6535
Practice Address - Street 1:523 RIDGEBURY RD
Practice Address - Street 2:
Practice Address - City:SLATE HILL
Practice Address - State:NY
Practice Address - Zip Code:10973-4310
Practice Address - Country:US
Practice Address - Phone:845-355-1092
Practice Address - Fax:845-355-6535
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-20600-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5459553OtherAETNA
NY136227OtherVALUE OPTIONS
NY136227OtherVALUE OPTIONS