Healthcare Provider Details

I. General information

NPI: 1063920601
Provider Name (Legal Business Name): PENNY LOUISE POTTER SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PENNY LOUISE TREICHEL SUDCC

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 CEDAR ST.
ROCKLEDGE FL
32955
US

IV. Provider business mailing address

349 HARMONY PLACE
COCOA FL
32926
US

V. Phone/Fax

Practice location:
  • Phone: 321-890-1500
  • Fax: 707-526-0527
Mailing address:
  • Phone: 707-280-1705
  • Fax: 707-526-0527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12872-R
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: