Provider Demographics
NPI:1376844902
Name:SEVERSON, MICHAEL B (LCDC, CART)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:LCDC, CART
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4586
Mailing Address - Country:US
Mailing Address - Phone:830-377-3192
Mailing Address - Fax:
Practice Address - Street 1:625 CLAY ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4586
Practice Address - Country:US
Practice Address - Phone:830-377-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8909103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst