Provider Demographics
NPI:1629453675
Name:SEGALL THERAPEUTICS
Entity Type:Organization
Organization Name:SEGALL THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-859-1464
Mailing Address - Street 1:16 KLETSK HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2971
Mailing Address - Country:US
Mailing Address - Phone:732-859-1464
Mailing Address - Fax:
Practice Address - Street 1:220 FARADAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-5073
Practice Address - Country:US
Practice Address - Phone:732-859-1464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty