Healthcare Provider Details

I. General information

NPI: 1093150047
Provider Name (Legal Business Name): GARY POTTER COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 30TH AVE
KEARNEY NE
68845-4036
US

IV. Provider business mailing address

2811 30TH AVE
KEARNEY NE
68845-4036
US

V. Phone/Fax

Practice location:
  • Phone: 308-237-6865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1010
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1010
License Number StateNE

VIII. Authorized Official

Name: GARY POTTER
Title or Position: OWNER
Credential: LIMHP
Phone: 308-236-0726