Provider Demographics
NPI:1871140590
Name:SEALS, KEITH A (BS, SUDP, AAC, CPC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:SEALS
Suffix:
Gender:M
Credentials:BS, SUDP, AAC, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:900 FIR ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2544
Practice Address - Country:US
Practice Address - Phone:360-575-3316
Practice Address - Fax:360-353-9440
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP000006387101YA0400X
WACG60997138101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2140749Medicaid