Provider Demographics
NPI:1972662278
Name:SEVER, MARK JOSEPH (MSPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:SEVER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-1483
Mailing Address - Country:US
Mailing Address - Phone:707-887-0185
Mailing Address - Fax:707-887-1681
Practice Address - Street 1:6478 MIRABEL RD
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:CA
Practice Address - Zip Code:95436-1483
Practice Address - Country:US
Practice Address - Phone:707-887-0185
Practice Address - Fax:707-887-1681
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0113880Medicaid
CAPT0113880Medicaid
0PT113880Medicare PIN