Basic Information
Provider Information
NPI: 1003140245
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SEALS
FirstName: OCTAVIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1221 W LAKEVIEW AVE
Address2:  
City: PENSACOLA
State: FL
PostalCode: 325011857
CountryCode: US
TelephoneNumber: 8504693500
FaxNumber: 8505951400
Practice Location
Address1: 1221 W LAKEVIEW AVE
Address2:  
City: PENSACOLA
State: FL
PostalCode: 325011857
CountryCode: US
TelephoneNumber: 8504693500
FaxNumber: 8505951400
Other Information
ProviderEnumerationDate: 09/21/2009
LastUpdateDate: 03/01/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XSW7868ZZY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
76659110005FL MEDICAID


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