Provider Demographics
NPI:1467878199
Name:SEVERHOF, EDWARD MALIO JR
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MALIO
Last Name:SEVERHOF
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2744
Mailing Address - Country:US
Mailing Address - Phone:419-574-2522
Mailing Address - Fax:
Practice Address - Street 1:4301 S FLAMINGO RD STE 101
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-1902
Practice Address - Country:US
Practice Address - Phone:954-312-3449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14195225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1467878199Medicaid