Provider Demographics
NPI:1326155607
Name:SEGALL, LAURENCE CHARLES (MS LCSW)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:CHARLES
Last Name:SEGALL
Suffix:
Gender:M
Credentials:MS LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 OLD HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-722-7763
Mailing Address - Fax:203-459-1226
Practice Address - Street 1:43 OLD HOLLOW ROAD
Practice Address - Street 2:STE 43
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611
Practice Address - Country:US
Practice Address - Phone:203-722-7763
Practice Address - Fax:203-459-1226
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001938051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004242997Medicaid
800000161Medicare ID - Type Unspecified