Provider Demographics
NPI:1518605021
Name:SEVERSON, SAMANTHA J (RD, CD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:ANGELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 W GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6911
Mailing Address - Country:US
Mailing Address - Phone:715-829-0212
Mailing Address - Fax:
Practice Address - Street 1:617 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6223
Practice Address - Country:US
Practice Address - Phone:715-839-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered