Provider Demographics
NPI:1184904864
Name:POTTER, GWENDOLYN KAYE
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:KAYE
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GWENDOLYN
Other - Middle Name:KAYE
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 SW G ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:541-476-1526
Practice Address - Street 1:1545 HARBECK RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5605
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-295-3069
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR03-07-35101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)