Provider Demographics
NPI:1154591527
Name:SEGAL, MARK IAN (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:IAN
Last Name:SEGAL
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 TRURO LN
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1203
Mailing Address - Country:US
Mailing Address - Phone:443-292-4164
Mailing Address - Fax:
Practice Address - Street 1:931 TRURO LN
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1203
Practice Address - Country:US
Practice Address - Phone:443-292-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-02
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD118381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0588059 00Medicaid