Provider Demographics
NPI:1184754632
Name:SEGLIN, MARK H (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:SEGLIN
Suffix:
Gender:M
Credentials:PHD
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 32396
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102
Mailing Address - Country:US
Mailing Address - Phone:973-325-3131
Mailing Address - Fax:973-645-9894
Practice Address - Street 1:89 LAPIS CIR
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2154
Practice Address - Country:US
Practice Address - Phone:973-325-3131
Practice Address - Fax:973-645-9894
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2138103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1596306Medicaid