MEDICARE: ELLEN M SEVERSON MSSA, LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I0009998	OH

General Provider Information

NPI Number	:	1295883387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN M SEVERSON MSSA, LISW

Provider Business Mailing Address
First Line	:	23725 WOLF RD
Second Line	:
City	:	BAY VILLAGE
State	:	OH
Zip	:	44140-2854
Country	:	US
Telephone Number	:	216-849-6165
Fax Number	:	440-471-4948

Provider Business Practice Location Address
First Line	:	402 SANDHURST DR
Second Line	:
City	:	HIGHLAND HEIGHTS
State	:	OH
Zip	:	44143-3604
Country	:	US
Telephone Number	:	216-201-0339
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	01/31/2011

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