=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003094780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS RECOVERY CENTER, INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2008
-----------------------------------------------------
Last Update Date | 03/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 E COURT ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28752-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-659-8626
-----------------------------------------------------
Fax | 828-659-6383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1864
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28752-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-659-8626
-----------------------------------------------------
Fax | 828-659-6383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. WILLIAM HOLLIS POTTER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 828-659-8626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 4731
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------