Provider Demographics
NPI:1710731294
Name:SEVERANCE, LEANNA
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:
Last Name:SEVERANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 ORAN DELPHI RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9338
Mailing Address - Country:US
Mailing Address - Phone:315-662-7103
Mailing Address - Fax:
Practice Address - Street 1:329 N SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1755
Practice Address - Country:US
Practice Address - Phone:315-471-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267088163WP0808X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health