Provider Demographics
NPI:1063920601
Name:POTTER, PENNY LOUISE (SUDCC)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:LOUISE
Last Name:POTTER
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:LOUISE
Other - Last Name:TREICHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDCC
Mailing Address - Street 1:349 HARMONY PLACE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926
Mailing Address - Country:US
Mailing Address - Phone:707-280-1705
Mailing Address - Fax:707-526-0527
Practice Address - Street 1:1770 CEDAR ST.
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-890-1500
Practice Address - Fax:707-526-0527
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CA12872-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)