1629189378 NPI number — MR. GLEN THOMAS SEGOND LCSW

Table of content: MR. GLEN THOMAS SEGOND LCSW (NPI 1629189378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629189378 NPI number — MR. GLEN THOMAS SEGOND LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEGOND
Provider First Name:
GLEN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629189378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 2 BOX 2205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-9639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-424-6049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-424-6049
Provider Business Practice Location Address Fax Number:
570-424-0917
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW004643L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 44SC05112500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5013039 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: SE690000 . This is a "HIGHMARK BS FED EMPL PROV" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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