Provider Demographics
NPI:1255737334
Name:SAULS, KEANE QUANTAZE SR (LCAS)
Entity type:Individual
Prefix:MR
First Name:KEANE
Middle Name:QUANTAZE
Last Name:SAULS
Suffix:SR
Gender:M
Credentials:LCAS
Other - Prefix:MR
Other - First Name:KEANE
Other - Middle Name:QUANTAZE
Other - Last Name:SAULS
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:LCAS
Mailing Address - Street 1:1709 CENTRE ST W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2781
Mailing Address - Country:US
Mailing Address - Phone:919-737-4895
Mailing Address - Fax:
Practice Address - Street 1:1709 CENTRE ST W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2781
Practice Address - Country:US
Practice Address - Phone:919-801-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13875101YA0400X
NC20283101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)