Provider Demographics
NPI:1760799886
Name:SEGURA HERNANDEZ, GUSTAVO (PHD, MP, ABPP)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:SEGURA HERNANDEZ
Suffix:
Gender:M
Credentials:PHD, MP, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1195
Mailing Address - Country:US
Mailing Address - Phone:727-834-0034
Mailing Address - Fax:
Practice Address - Street 1:1502 STUBBS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5628
Practice Address - Country:US
Practice Address - Phone:727-834-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9350103TB0200X
LA334132103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral