Healthcare Provider Details

I. General information

NPI: 1265888259
Provider Name (Legal Business Name): CHARLES POTTER MA, LPCC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

IV. Provider business mailing address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 513-939-0300
  • Fax: 513-939-0310
Mailing address:
  • Phone: 513-939-0300
  • Fax: 513-939-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.1901087-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: