Provider Demographics
NPI:1295883387
Name:SEVERSON, ELLEN M (MSSA, LISW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:MSSA, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23725 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2854
Mailing Address - Country:US
Mailing Address - Phone:216-849-6165
Mailing Address - Fax:440-471-4948
Practice Address - Street 1:402 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-3604
Practice Address - Country:US
Practice Address - Phone:216-201-0339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00099981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW29253Medicare PIN