Provider Demographics
NPI:1063965721
Name:SENGSAVANG, KEO
Entity type:Individual
Prefix:
First Name:KEO
Middle Name:
Last Name:SENGSAVANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 BEAR PATH TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2218
Mailing Address - Country:US
Mailing Address - Phone:612-234-2397
Mailing Address - Fax:
Practice Address - Street 1:4361 BEAR PATH TRL
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2218
Practice Address - Country:US
Practice Address - Phone:612-234-2397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional