Basic Information
| Provider Information | |||||||||
| NPI: | 1184212656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEGEV | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | DARA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3773 PLUM HILL CT | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210425122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103009275 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9030 ROUTE 108 STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210451990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107401901 | ||||||||
| FaxNumber: | 4107402503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2021 | ||||||||
| LastUpdateDate: | 01/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 20282 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.