Basic Information
| Provider Information | |||||||||
| NPI: | 1629309125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEVERSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST | ||||||||
| Address2: | SUITE 625 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245681 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2017 JEFFERSON ST SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240142419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408530900 | ||||||||
| FaxNumber: | 5408530518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 01/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904007302 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.