Provider Demographics
NPI:1790267847
Name:POTTER, GREGORY CHARLES (LCSW, LCADC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CHARLES
Last Name:POTTER
Suffix:
Gender:M
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 TURKEY TOP RD
Mailing Address - Street 2:
Mailing Address - City:PORT MURRAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07865-3003
Mailing Address - Country:US
Mailing Address - Phone:908-625-0989
Mailing Address - Fax:
Practice Address - Street 1:336 TURKEY TOP RD
Practice Address - Street 2:
Practice Address - City:PORT MURRAY
Practice Address - State:NJ
Practice Address - Zip Code:07865-3003
Practice Address - Country:US
Practice Address - Phone:908-625-0989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05754100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health