Healthcare Provider Details

I. General information

NPI: 1730413998
Provider Name (Legal Business Name): MARK A POTTS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DOBH CHILD AND FAMILY CLINIC 2817 REILLY STREET
FORT LIBERTY NC
28310-1343
US

IV. Provider business mailing address

BLDG 4-3219 ROOM #G091, 2817 REILLY STREET
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-9191
  • Fax: 910-907-4201
Mailing address:
  • Phone: 910-907-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007217
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: