Provider Demographics
NPI:1083730725
Name:SEELY, KENNETH LEE (PH, D,)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:SEELY
Suffix:
Gender:M
Credentials:PH, D,
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 285
Mailing Address - Street 2:
Mailing Address - City:LA VERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-0285
Mailing Address - Country:US
Mailing Address - Phone:435-635-6028
Mailing Address - Fax:
Practice Address - Street 1:150 N STATE ST
Practice Address - Street 2:
Practice Address - City:LA VERKIN
Practice Address - State:UT
Practice Address - Zip Code:84745-5503
Practice Address - Country:US
Practice Address - Phone:435-635-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116404-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical