Provider Demographics
NPI:1235278334
Name:SEVERINO-CLEMENTE, MARY AGNES (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AGNES
Last Name:SEVERINO-CLEMENTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:AGNES
Other - Middle Name:
Other - Last Name:CLEMENTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:11442 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-3334
Mailing Address - Country:US
Mailing Address - Phone:818-687-8981
Mailing Address - Fax:818-435-2081
Practice Address - Street 1:11442 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-3334
Practice Address - Country:US
Practice Address - Phone:818-687-8981
Practice Address - Fax:818-435-2081
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT21507OtherPROVIDER NUMBER