Provider Demographics
NPI:1598821217
Name:SEVERANCE, MELISSA B (MA LP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:SEVERANCE
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 STILLWATER BLVD N STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8613
Mailing Address - Country:US
Mailing Address - Phone:651-777-3336
Mailing Address - Fax:
Practice Address - Street 1:11550 STILLWATER BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8613
Practice Address - Country:US
Practice Address - Phone:651-777-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3637103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41D05SEOtherBCBS INDIVIDUAL PROVIDER
MN41D04SEOtherBCBS GROUP NUMBER
MN6292882OtherMEDICA ID