Healthcare Provider Details

I. General information

NPI: 1417334319
Provider Name (Legal Business Name): TAMARA MARIE SEGRIST LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FREEDOM DR
NAPOLEON OH
43545-9038
US

IV. Provider business mailing address

4880 COUNTY ROAD 10 2
WAUSEON OH
43567-9582
US

V. Phone/Fax

Practice location:
  • Phone: 419-599-1660
  • Fax: 419-592-8336
Mailing address:
  • Phone: 419-599-1660
  • Fax: 419-592-8336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS1200045
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: