Provider Demographics
NPI:1205022316
Name:SEVERSON, DEBRA JILL (MS LPC)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:JILL
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 1 1/2 ST
Mailing Address - Street 2:PO BOX 27
Mailing Address - City:COMSTOCK
Mailing Address - State:WI
Mailing Address - Zip Code:54826-0027
Mailing Address - Country:US
Mailing Address - Phone:715-822-2075
Mailing Address - Fax:714-822-2205
Practice Address - Street 1:23758 STATE ROAD 35
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-0356
Practice Address - Country:US
Practice Address - Phone:715-349-8913
Practice Address - Fax:715-349-8981
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1116 125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1116 125OtherPROFESSIONAL COUNSELOR
WI39772500Medicaid