Provider Demographics
NPI:1669638870
Name:SEVERSON, CORINN (MA)
Entity Type:Individual
Prefix:
First Name:CORINN
Middle Name:
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 N PROSPECT AVE
Mailing Address - Street 2:#911
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1973
Mailing Address - Country:US
Mailing Address - Phone:218-831-6931
Mailing Address - Fax:
Practice Address - Street 1:1732 N PROSPECT AVE
Practice Address - Street 2:#911
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1973
Practice Address - Country:US
Practice Address - Phone:218-831-6931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3107-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist