Healthcare Provider Details

I. General information

NPI: 1891082947
Provider Name (Legal Business Name): GREGORY L POTTS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

525 W HAWTHORNE PL APT 308
CHICAGO IL
60657-9266
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax: 773-765-0794
Mailing address:
  • Phone: 773-655-9304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014179
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: