1104957307 NPI number — CAROL A SEVERSON LDM,CPM

Table of content: CAROL A SEVERSON LDM,CPM (NPI 1104957307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104957307 NPI number — CAROL A SEVERSON LDM,CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVERSON
Provider First Name:
CAROL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LDM,CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104957307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2532 SANTIAM HWY SE
Provider Second Line Business Mailing Address:
PMB 314
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97322-5211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-928-1002
Provider Business Mailing Address Fax Number:
541-327-2721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 SHORTRIDGE ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97322-6934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-928-1002
Provider Business Practice Location Address Fax Number:
541-327-2721
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  DEM-LD102953 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 140058 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98040016 . This is a "NARM" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: LDM-LD 102953 . This is a "HEALTH LICENSING BOARD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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