Provider Demographics
NPI:1437783404
Name:SEVERIN, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:SEVERIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SHILOH RD NW STE 340
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7151
Mailing Address - Country:US
Mailing Address - Phone:678-386-9995
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW STE 340
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7151
Practice Address - Country:US
Practice Address - Phone:678-386-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health