Provider Demographics
NPI:1437407780
Name:SEGURA, PAMELA SHONTAY (MS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SHONTAY
Last Name:SEGURA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79512-0579
Mailing Address - Country:US
Mailing Address - Phone:407-914-8373
Mailing Address - Fax:352-646-7144
Practice Address - Street 1:792 E MONTROSE ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2644
Practice Address - Country:US
Practice Address - Phone:407-914-8373
Practice Address - Fax:352-646-7144
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 171M00000X, 172A00000X, 390200000X
FLIMH12501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program