MEDICARE: MR. GREGORY CHARLES POTTER LCSW, LCADC

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	101YM0800X	Mental Health Counselor	44SC05754100	NJ

General Provider Information

NPI Number	:	1790267847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY CHARLES POTTER LCSW, LCADC

Provider Business Mailing Address
First Line	:	336 TURKEY TOP RD
Second Line	:
City	:	PORT MURRAY
State	:	NJ
Zip	:	07865-3003
Country	:	US
Telephone Number	:	908-625-0989
Fax Number	:

Provider Business Practice Location Address
First Line	:	336 TURKEY TOP RD
Second Line	:
City	:	PORT MURRAY
State	:	NJ
Zip	:	07865-3003
Country	:	US
Telephone Number	:	908-625-0989
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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