Provider Demographics
NPI:1780916122
Name:SEVERSON, MICHELLE REBECCA (DC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:REBECCA
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 TANYARD RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-1543
Mailing Address - Country:US
Mailing Address - Phone:540-483-4344
Mailing Address - Fax:844-726-9867
Practice Address - Street 1:920 TANYARD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1543
Practice Address - Country:US
Practice Address - Phone:540-483-3678
Practice Address - Fax:540-483-3820
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556868111N00000X
PADC010498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05545OtherMEDICARE GROUP PTAN
VAC05545OtherMEDICARE GROUP PTAN