Provider Demographics
NPI:1508182866
Name:SEVERINO, MARK THOMAS (SLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:SEVERINO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-4540
Mailing Address - Country:US
Mailing Address - Phone:410-887-1212
Mailing Address - Fax:
Practice Address - Street 1:2901 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-4540
Practice Address - Country:US
Practice Address - Phone:410-887-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6273235Z00000X
MD10010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist