Healthcare Provider Details

I. General information

NPI: 1568049674
Provider Name (Legal Business Name): MS. EBONIE DANIELLE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CAROLINA ST
GREENSBORO NC
27401-1032
US

IV. Provider business mailing address

4910 KOGER BLVD APT 3H
GREENSBORO NC
27407-2794
US

V. Phone/Fax

Practice location:
  • Phone: 336-542-2060
  • Fax:
Mailing address:
  • Phone: 336-254-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA16402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: