Provider Demographics
NPI:1457611394
Name:D L SEVERSON, SPEECH PATHOLOGIST, PLLC
Entity Type:Organization
Organization Name:D L SEVERSON, SPEECH PATHOLOGIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:918-766-3383
Mailing Address - Street 1:1430 HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-5417
Mailing Address - Country:US
Mailing Address - Phone:918-766-3383
Mailing Address - Fax:
Practice Address - Street 1:5204 JACQUELYN LN
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-7733
Practice Address - Country:US
Practice Address - Phone:918-766-3383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2561235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1215168570Medicaid