Healthcare Provider Details

I. General information

NPI: 1225147960
Provider Name (Legal Business Name): THE POTTER'S HOUSE SUBSTANCE ABUSE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W NORTHERN AVE STE 101
PHOENIX AZ
85021-5400
US

IV. Provider business mailing address

1717 W NORTHERN AVE STE 101
PHOENIX AZ
85021-5400
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-9701
  • Fax: 602-252-0830
Mailing address:
  • Phone: 602-254-9701
  • Fax: 602-252-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH3520
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberLISAC-10784
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHEENA ROSETTE JONES
Title or Position: VICE PRESIDENT
Credential:
Phone: 602-254-9701