Provider Demographics
NPI:1831444876
Name:POTTER, GINA MARIE (MSW)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 S LYNHURST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-8630
Mailing Address - Country:US
Mailing Address - Phone:317-247-8900
Mailing Address - Fax:317-247-8938
Practice Address - Street 1:2345 S LYNHURST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-8630
Practice Address - Country:US
Practice Address - Phone:317-247-8900
Practice Address - Fax:317-247-8938
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99052084A1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool