Provider Demographics
NPI:1801018841
Name:SEVERSON, KRYSTA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 21ST ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3811
Mailing Address - Country:US
Mailing Address - Phone:701-238-9433
Mailing Address - Fax:
Practice Address - Street 1:1606 29TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5923
Practice Address - Country:US
Practice Address - Phone:701-261-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist