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General NPI Number Information
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NPI Number | 1619155504
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Entity Type | Organization
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Legal Business Name | SOGC INC
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 06/20/2008
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Provider Practice Location Address
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Address Line | 14542 61ST AVE.
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City | BLUE GRASS
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State | IA
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Zip | 52726-9592
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Country | US
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Telephone | 563-381-4649
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Fax | 563-381-4649
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Provider Business Mailing Address
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Address Line | 14542 61ST AVE.
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City | BLUE GRASS
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State | IA
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Zip | 52726-9592
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Country | US
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Telephone | 563-381-4649
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Fax | 563-381-4649
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Authorized Official
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Title or Position | DIRECTOR OF THERAPEUTIC SERVICES
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Name | MRS. SUSAN LEE POTTHAST
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Credential | LMHC, LMT
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Telephone | 563-381-4649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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