MEDICARE: MS. THERESA POTTER ACSW LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	34000816A	IN

General Provider Information

NPI Number	:	1215075700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESA POTTER ACSW LCSW

Provider Business Mailing Address
First Line	:	7202 NORTH SHADELAND AVENUE
Second Line	:	SUITE 127
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250
Country	:	US
Telephone Number	:	317-849-9646
Fax Number	:	317-849-9651

Provider Business Practice Location Address
First Line	:	7202 NORTH SHADELAND AVENUE
Second Line	:	SUITE 127
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250
Country	:	US
Telephone Number	:	317-849-9646
Fax Number	:	317-849-9651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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