Healthcare Provider Details

I. General information

NPI: 1497759419
Provider Name (Legal Business Name): EFRAIN SEGARRA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5557 CARYS BROOK LN
GLOUCESTER VA
23061-2002
US

IV. Provider business mailing address

5557 CARYS BROOK LN
GLOUCESTER VA
23061-2002
US

V. Phone/Fax

Practice location:
  • Phone: 757-344-6747
  • Fax: 804-695-1815
Mailing address:
  • Phone: 757-344-6747
  • Fax: 804-695-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810001283
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0810001283
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number0810001283
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810001283
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number0810001283
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810001283
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number0810001283
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number0810001283
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0810001283
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: