MEDICARE: GREGORY POTTS LCSW LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1184223018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY POTTS LCSW LLC

Provider Business Mailing Address
First Line	:	525 W HAWTHORNE PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-2907
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 W HAWTHORNE PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-2907
Country	:	US
Telephone Number	:	872-239-6769
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY POTTS
Credential	:
Telephone Number	:	872-239-6769

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	10/21/2020

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