Provider Demographics
NPI:1134424690
Name:SEVERINO, LISA LLEWELLYN (LAC, MAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LLEWELLYN
Last Name:SEVERINO
Suffix:
Gender:F
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12442 STOTTLEMYER RD
Mailing Address - Street 2:
Mailing Address - City:MYERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21773-9600
Mailing Address - Country:US
Mailing Address - Phone:301-606-7657
Mailing Address - Fax:
Practice Address - Street 1:1446 W PATRICK ST
Practice Address - Street 2:UNIT 14
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-3200
Practice Address - Country:US
Practice Address - Phone:301-606-7657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01720171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist