Provider Demographics
NPI:1407004047
Name:POTTER, GEORGE BENJAMIN (CAC-AD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:BENJAMIN
Last Name:POTTER
Suffix:
Gender:M
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 BALTIMORE BLVD
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7098
Mailing Address - Country:US
Mailing Address - Phone:410-871-3005
Mailing Address - Fax:443-293-8711
Practice Address - Street 1:1130 BALTIMORE BLVD
Practice Address - Street 2:SUITE C-2
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7098
Practice Address - Country:US
Practice Address - Phone:410-871-3005
Practice Address - Fax:443-293-8711
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)