Healthcare Provider Details

I. General information

NPI: 1295790806
Provider Name (Legal Business Name): THOMAS W POTTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 NE D STREET STE C
STIGLER OK
74462
US

IV. Provider business mailing address

1407 NE D STREET STE C
STIGLER OK
74462
US

V. Phone/Fax

Practice location:
  • Phone: 918-967-3368
  • Fax: 918-967-3351
Mailing address:
  • Phone: 918-967-3368
  • Fax: 918-967-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: