MEDICARE: TIA ROSE POTTS BS OF PSYCHOLOGY

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457361735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIA ROSE POTTS BS OF PSYCHOLOGY

Provider Business Mailing Address
First Line	:	20075 NORTHVILLE PLACE DR APT 3106
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-2961
Country	:	US
Telephone Number	:	248-773-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 E 12 MILE RD
Second Line	:
City	:	MADISON HTS
State	:	MI
Zip	:	48071-2651
Country	:	US
Telephone Number	:	248-547-2223
Fax Number	:	248-547-2226

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	04/08/2008

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