Healthcare Provider Details

I. General information

NPI: 1063965721
Provider Name (Legal Business Name): KEO SENGSAVANG MA, LPCC, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34990 EMERALD COAST PKWY STE 356
DESTIN FL
32541-8662
US

IV. Provider business mailing address

34990 EMERALD COAST PKWY STE 356
DESTIN FL
32541-8662
US

V. Phone/Fax

Practice location:
  • Phone: 612-234-1823
  • Fax:
Mailing address:
  • Phone: 612-234-1823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2883
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: