Provider Demographics
NPI:1245521459
Name:POTTER-GALLANT, LINDA (MA, LLP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:POTTER-GALLANT
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:9329 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1260
Mailing Address - Country:US
Mailing Address - Phone:313-937-9500
Mailing Address - Fax:
Practice Address - Street 1:9329 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-937-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012716103TC0700X
MI6361007186103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical