MEDICARE: JUSTIN SEGURA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	242.004501	IL

General Provider Information

NPI Number	:	1609390236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN SEGURA

Provider Business Mailing Address
First Line	:	9820 N CENTRAL AVE UNIT 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-1054
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9820 N CENTRAL AVE UNIT 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-1054
Country	:	US
Telephone Number	:	309-299-8833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2017
Last Update Date	:	07/26/2017

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Directions to “ JUSTIN SEGURA ” Practice Location

Language	Start Address	Practice Location

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