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
StateLicense IDTaxonomies
PACW004643L1041C0700X
NJ44SC051125001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5013039OtherAETNA PROVIDER NUMBER
PASE690000OtherHIGHMARK BS FED EMPL PROV
PA690000Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER