Provider Demographics
NPI:1871077982
Name:SEGERSON, MICHAEL SINCLAIR (COTA/L)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SINCLAIR
Last Name:SEGERSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 WILSON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-3786
Mailing Address - Country:US
Mailing Address - Phone:731-435-0104
Mailing Address - Fax:
Practice Address - Street 1:104 WATSON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-4510
Practice Address - Country:US
Practice Address - Phone:615-384-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3153224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant