Healthcare Provider Details

I. General information

NPI: 1154591527
Provider Name (Legal Business Name): MARK IAN SEGAL LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2008
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 TRURO LN
CROFTON MD
21114-1203
US

IV. Provider business mailing address

931 TRURO LN
CROFTON MD
21114-1203
US

V. Phone/Fax

Practice location:
  • Phone: 443-292-4164
  • Fax:
Mailing address:
  • Phone: 443-292-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11838
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: