1770916025 NPI number — ERIKA MARIE SEVERSON LICSW

Table of content: ERIKA MARIE SEVERSON LICSW (NPI 1770916025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770916025 NPI number — ERIKA MARIE SEVERSON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVERSON
Provider First Name:
ERIKA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSTAD
Provider Other First Name:
ERIKA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770916025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROOKSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56716-0603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-281-3940
Provider Business Mailing Address Fax Number:
218-281-6261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1422 CENTRAL AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST GRAND FORKS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-281-3940
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2013

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 20630 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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