Provider Demographics
NPI:1396414173
Name:SEVERSON, SHIONA (SAC-IT)
Entity Type:Individual
Prefix:MRS
First Name:SHIONA
Middle Name:
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 12TH AVE S APT 13
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3475
Mailing Address - Country:US
Mailing Address - Phone:608-790-0502
Mailing Address - Fax:
Practice Address - Street 1:319 MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-0709
Practice Address - Country:US
Practice Address - Phone:608-796-1114
Practice Address - Fax:608-200-7292
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI19552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty