Healthcare Provider Details

I. General information

NPI: 1326382490
Provider Name (Legal Business Name): KYLE SEELEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W 5TH ST
SHERIDAN WY
82801-2701
US

IV. Provider business mailing address

909 LONG DR STE C
SHERIDAN WY
82801-3282
US

V. Phone/Fax

Practice location:
  • Phone: 307-674-4405
  • Fax:
Mailing address:
  • Phone: 307-672-8958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1675
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: