Provider Demographics
NPI:1003785122
Name:POTARACKE, MARK THOMAS (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:POTARACKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1241
Mailing Address - Country:US
Mailing Address - Phone:608-451-5622
Mailing Address - Fax:
Practice Address - Street 1:209 TIMBERLAKE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1241
Practice Address - Country:US
Practice Address - Phone:608-451-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0190931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical