Provider Demographics
NPI:1326159930
Name:POTTER, GARY O (LMHP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:O
Last Name:POTTER
Suffix:
Gender:M
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 AVENUE A
Mailing Address - Street 2:SUITE E
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8169
Mailing Address - Country:US
Mailing Address - Phone:308-234-5644
Mailing Address - Fax:308-234-5652
Practice Address - Street 1:3720 AVENUE A
Practice Address - Street 2:SUITE E
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8169
Practice Address - Country:US
Practice Address - Phone:308-234-5644
Practice Address - Fax:308-234-5652
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2163101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE486558000OtherMAGELLAN MIS
NE470808292OtherMIDLANDS CHOICE
NE470808292OtherTRICARE
NE84793OtherBC/BS
NE47080829226Medicaid