Provider Demographics
NPI:1033269741
Name:SEVERSON, RANDOLPH WILL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:WILL
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 NORTH CENTRAL EXPRESSWAY
Mailing Address - Street 2:#3026
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3447
Mailing Address - Country:US
Mailing Address - Phone:214-521-4560
Mailing Address - Fax:
Practice Address - Street 1:5025 NORTH CENTRAL EXPRESSWAY
Practice Address - Street 2:#3026
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3447
Practice Address - Country:US
Practice Address - Phone:214-521-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3216101YP2500X
TX000329021428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6110LCOtherBLUE CROSS BLUE SHIELD PR