Provider Demographics
NPI:1013157650
Name:SEVERSON, LORETTA LEE (PSYD)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:LEE
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:PSYD
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 92
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04460-0092
Mailing Address - Country:US
Mailing Address - Phone:207-290-1924
Mailing Address - Fax:
Practice Address - Street 1:51 MAIN ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1439
Practice Address - Country:US
Practice Address - Phone:207-290-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433573599Medicaid
ME433573599Medicaid