Healthcare Provider Details

I. General information

NPI: 1548776388
Provider Name (Legal Business Name): KEITH S TRUDEL LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 MAIN ST
LIMESTONE ME
04750-6607
US

IV. Provider business mailing address

180 ACADEMY ST STE 3
PRESQUE ISLE ME
04769-3183
US

V. Phone/Fax

Practice location:
  • Phone: 207-498-6431
  • Fax:
Mailing address:
  • Phone: 207-554-2352
  • Fax: 207-554-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCAC6403
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC6841
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: