=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760807770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTTERS ADULT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 04/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8255 2ND AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-355-8333
-----------------------------------------------------
Fax | 313-557-5129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18701 GRAND RIVER AVE SUITE 207
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48223-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-355-8333
-----------------------------------------------------
Fax | 313-557-5129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GWENDOLYN TURNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-574-0795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225800000X
-----------------------------------------------------
Taxonomy Name | Recreation Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------