Healthcare Provider Details

I. General information

NPI: 1902618077
Provider Name (Legal Business Name): PELICANO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 POYDRAS ST STE 1770
NEW ORLEANS LA
70112-5204
US

IV. Provider business mailing address

1645 PALM BEACH LAKES BLVD STE 1200
WEST PALM BEACH FL
33401-2214
US

V. Phone/Fax

Practice location:
  • Phone: 727-834-0034
  • Fax:
Mailing address:
  • Phone: 727-834-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. GUSTAVO SEGURA HERNANDEZ
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 727-834-0034