Provider Demographics
NPI:1316383219
Name:SEVERTSEN, ALEXA (LMP)
Entity Type:Individual
Prefix:MS
First Name:ALEXA
Middle Name:
Last Name:SEVERTSEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 25TH AVE NE
Mailing Address - Street 2:STE 104
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4915 25TH AVE NE
Practice Address - Street 2:STE 104
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5667
Practice Address - Country:US
Practice Address - Phone:206-315-7998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60178698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist