Provider Demographics
NPI:1407000383
Name:PENNA, FLOYD MARTIN (LPC, CADC III, CSAT)
Entity Type:Individual
Prefix:
First Name:FLOYD
Middle Name:MARTIN
Last Name:PENNA
Suffix:
Gender:M
Credentials:LPC, CADC III, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12414 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1044
Mailing Address - Country:US
Mailing Address - Phone:503-997-8664
Mailing Address - Fax:503-254-2196
Practice Address - Street 1:12414 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1044
Practice Address - Country:US
Practice Address - Phone:503-997-8664
Practice Address - Fax:503-254-2196
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09-12-74101YA0400X
ORC2177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407000383Medicaid