Healthcare Provider Details

I. General information

NPI: 1457361735
Provider Name (Legal Business Name): TIA ROSE POTTS BS OF PSYCHOLOGY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E 12 MILE RD
MADISON HTS MI
48071-2651
US

IV. Provider business mailing address

20075 NORTHVILLE PLACE DR APT 3106
NORTHVILLE MI
48167-2961
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-2223
  • Fax: 248-547-2226
Mailing address:
  • Phone: 248-773-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: