Healthcare Provider Details

I. General information

NPI: 1558816645
Provider Name (Legal Business Name): YTAMAR SEGALL MA, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 91ST ST
SURFSIDE FL
33154-3131
US

IV. Provider business mailing address

624 91ST ST
SURFSIDE FL
33154-3131
US

V. Phone/Fax

Practice location:
  • Phone: 702-374-7148
  • Fax:
Mailing address:
  • Phone: 702-374-7148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-17-8022
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT1624285
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-29543
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: