Provider Demographics
NPI:1871131284
Name:SEGOVIANO, JOSEPH PATRICK
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PATRICK
Last Name:SEGOVIANO
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 1:800 S MCHENRY AVE STE F
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7487
Mailing Address - Country:US
Mailing Address - Phone:224-436-4741
Mailing Address - Fax:
Practice Address - Street 1:800 S MCHENRY AVE STE F
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7487
Practice Address - Country:US
Practice Address - Phone:224-436-4741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health