Provider Demographics
NPI:1487321899
Name:TRUSSELL, KEEGAN RAINE (LPC)
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:RAINE
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-3372
Mailing Address - Country:US
Mailing Address - Phone:817-694-6460
Mailing Address - Fax:
Practice Address - Street 1:100 AUSTIN AVE STE 206
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-3382
Practice Address - Country:US
Practice Address - Phone:817-694-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82505101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health