Provider Demographics
NPI:1306462130
Name:SEGURA TRISTA, SERGUEY ENRIQUE
Entity type:Individual
Prefix:
First Name:SERGUEY
Middle Name:ENRIQUE
Last Name:SEGURA TRISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13402 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-1142
Mailing Address - Country:US
Mailing Address - Phone:786-457-9860
Mailing Address - Fax:
Practice Address - Street 1:13402 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1142
Practice Address - Country:US
Practice Address - Phone:786-457-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-75331103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst