Provider Demographics
NPI:1891082947
Name:POTTS, GREGORY L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:L
Last Name:POTTS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:525 W HAWTHORNE PL APT 308
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9266
Mailing Address - Country:US
Mailing Address - Phone:773-655-9304
Mailing Address - Fax:
Practice Address - Street 1:4740 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4689
Practice Address - Country:US
Practice Address - Phone:773-769-0205
Practice Address - Fax:773-765-0794
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490141791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616824OtherBLUE CROSS BLUE SHIELD