Healthcare Provider Details

I. General information

NPI: 1790778926
Provider Name (Legal Business Name): KEDRIC CECIL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 3RD AVE
HAVRE MT
59501-3576
US

IV. Provider business mailing address

PO BOX 1903
HAVRE MT
59501-1903
US

V. Phone/Fax

Practice location:
  • Phone: 406-265-5827
  • Fax: 406-265-5949
Mailing address:
  • Phone: 406-265-5827
  • Fax: 406-265-5949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number87LCPC
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: