MEDICARE: LEWIS PAIGE SEGO II MA LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	3839	MN

General Provider Information

NPI Number	:	1437898160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEWIS PAIGE SEGO II MA LMFT

Provider Business Mailing Address
First Line	:	102 MARTY DR STE 2
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-9345
Country	:	US
Telephone Number	:	763-682-5420
Fax Number	:	763-682-5413

Provider Business Practice Location Address
First Line	:	102 MARTY DR STE 2
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-9345
Country	:	US
Telephone Number	:	763-682-5420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2022
Last Update Date	:	06/01/2022

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