Provider Demographics
NPI:1548776388
Name:TRUDEL, KEITH S (LADC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:TRUDEL
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ACADEMY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3183
Mailing Address - Country:US
Mailing Address - Phone:207-554-2352
Mailing Address - Fax:207-554-2351
Practice Address - Street 1:382 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMESTONE
Practice Address - State:ME
Practice Address - Zip Code:04750-6607
Practice Address - Country:US
Practice Address - Phone:207-498-6431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC6403101Y00000X
MELC6841101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor