Healthcare Provider Details

I. General information

NPI: 1285825596
Provider Name (Legal Business Name): SEVILLA INGERSOLL LOVE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SEVILLA LYNN INGERSOLL LCSW

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 TESHLAR DR
ANCHORAGE AK
99507-2218
US

IV. Provider business mailing address

6501 TESHLAR DR
ANCHORAGE AK
99507-2218
US

V. Phone/Fax

Practice location:
  • Phone: 907-887-6269
  • Fax: 907-887-6269
Mailing address:
  • Phone: 907-887-6269
  • Fax: 907-887-6269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAA702
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierDA4460
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
IdentifierAA702
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerSTATE OF ALASKA
# 3
IdentifierMH4238
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: