Healthcare Provider Details

I. General information

NPI: 1437407780
Provider Name (Legal Business Name): PAMELA SHONTAY SEGURA M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 E MONTROSE ST
CLERMONT FL
34711-2644
US

IV. Provider business mailing address

PO BOX 579
COLORADO CITY TX
79512-0579
US

V. Phone/Fax

Practice location:
  • Phone: 407-914-8373
  • Fax: 352-646-7144
Mailing address:
  • Phone: 407-914-8373
  • Fax: 352-646-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH12501
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: