Provider Demographics
NPI:1235126277
Name:POTTER, GLORIA ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:ROSE
Last Name:POTTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 MORTHLAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-4637
Mailing Address - Country:US
Mailing Address - Phone:219-464-0106
Mailing Address - Fax:219-462-7826
Practice Address - Street 1:660 MORTHLAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-4637
Practice Address - Country:US
Practice Address - Phone:219-464-0106
Practice Address - Fax:219-462-7826
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003809A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical