Healthcare Provider Details

I. General information

NPI: 1619155504
Provider Name (Legal Business Name): SOGC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14542 61ST AVE.
BLUE GRASS IA
52726-9592
US

IV. Provider business mailing address

14542 61ST AVE.
BLUE GRASS IA
52726-9592
US

V. Phone/Fax

Practice location:
  • Phone: 563-381-4649
  • Fax: 563-381-4649
Mailing address:
  • Phone: 563-381-4649
  • Fax: 563-381-4649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN LEE POTTHAST
Title or Position: DIRECTOR OF THERAPEUTIC SERVICES
Credential: LMHC, LMT
Phone: 563-381-4649