Provider Demographics
NPI:1790778926
Name:CECIL, KEDRIC (PHD)
Entity Type:Individual
Prefix:
First Name:KEDRIC
Middle Name:
Last Name:CECIL
Suffix:
Gender:M
Credentials:PHD
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 1903
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-1903
Mailing Address - Country:US
Mailing Address - Phone:406-265-5827
Mailing Address - Fax:406-265-5949
Practice Address - Street 1:305 3RD AVE
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3576
Practice Address - Country:US
Practice Address - Phone:406-265-5827
Practice Address - Fax:406-265-5949
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT87LCPC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0250926Medicaid