Provider Demographics
NPI:1528496148
Name:SEIDEL, SALLY (LCPC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SEIDEL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 26TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3617
Mailing Address - Country:US
Mailing Address - Phone:406-799-0424
Mailing Address - Fax:
Practice Address - Street 1:2622 16TH AVE S APT 8
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5265
Practice Address - Country:US
Practice Address - Phone:406-799-0424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSWP-LCPC-LIC-4615101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1528496148Medicaid
521966OtherMHN