Provider Demographics
NPI:1841761699
Name:SEVERN, DON LYLE (CI21700218 (CADC 1 ))
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:LYLE
Last Name:SEVERN
Suffix:
Gender:M
Credentials:CI21700218 (CADC 1 )
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-4357
Mailing Address - Country:US
Mailing Address - Phone:510-619-3000
Mailing Address - Fax:510-235-2545
Practice Address - Street 1:1515 MARKET AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-4357
Practice Address - Country:US
Practice Address - Phone:510-619-3000
Practice Address - Fax:510-235-2545
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI21700218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265560130Medicaid