Provider Demographics
NPI:1336381102
Name:SEVERANCE, ROREE CARTER (LADC)
Entity Type:Individual
Prefix:MS
First Name:ROREE
Middle Name:CARTER
Last Name:SEVERANCE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 BUNKER DR
Mailing Address - Street 2:
Mailing Address - City:OTIS
Mailing Address - State:ME
Mailing Address - Zip Code:04605-7619
Mailing Address - Country:US
Mailing Address - Phone:207-812-2133
Mailing Address - Fax:
Practice Address - Street 1:194 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-812-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4384101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431962399Medicaid