Provider Demographics
NPI: | 1629189378 |
---|---|
Name: | SEGOND, GLEN THOMAS (LCSW) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | GLEN |
Middle Name: | THOMAS |
Last Name: | SEGOND |
Suffix: | |
Gender: | M |
Credentials: | LCSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | RR 2 BOX 2205 |
Mailing Address - Street 2: | |
Mailing Address - City: | EAST STROUDSBURG |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 18301-9639 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 570-424-6049 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 117 BROAD ST |
Practice Address - Street 2: | |
Practice Address - City: | STROUDSBURG |
Practice Address - State: | PA |
Practice Address - Zip Code: | 18360-1534 |
Practice Address - Country: | US |
Practice Address - Phone: | 570-424-6049 |
Practice Address - Fax: | 570-424-0917 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-08-31 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | CW004643L | 1041C0700X |
NJ | 44SC05112500 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 5013039 | Other | AETNA PROVIDER NUMBER |
PA | SE690000 | Other | HIGHMARK BS FED EMPL PROV |
PA | 690000 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |