Basic Information
| Provider Information | |||||||||
| NPI: | 1407111461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEVILIS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALLO | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9110 COLLEGE POINTE CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339193244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392082212 | ||||||||
| FaxNumber: | 2392083994 | ||||||||
| Practice Location | |||||||||
| Address1: | 9110 COLLEGE POINTE CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339193244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392082212 | ||||||||
| FaxNumber: | 2392083994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2012 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 34.013178 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 15244 | ND | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 19093 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | DO190968 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 25733 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 5101023712 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 20A12490 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2015-02019 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | TM00771 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 293822-1 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | OS019683 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | OS15069 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 3116053 | 05 | NH | MEDICAID |