Provider Demographics
NPI:1912200726
Name:SEVERCOOL, REBECCA ELLSWORTH (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELLSWORTH
Last Name:SEVERCOOL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANNE
Other - Last Name:ELLSWORTH-SEVERCOOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:435 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1606
Mailing Address - Country:US
Mailing Address - Phone:607-763-3695
Mailing Address - Fax:
Practice Address - Street 1:435 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1606
Practice Address - Country:US
Practice Address - Phone:607-763-3695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003113235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist