Provider Demographics
NPI:1366786121
Name:SEAGRAVE, DANIEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:SEAGRAVE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MARTIN ARMY, 6600 VAN AALST BLVD
Mailing Address - Street 2:BLDG 9250
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:505-670-4484
Mailing Address - Fax:
Practice Address - Street 1:MARTIN ARMY, 6600 VAN AALST BLVD
Practice Address - Street 2:BLDG 9250
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:505-670-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-18
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM685103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical