Healthcare Provider Details

I. General information

NPI: 1467123836
Provider Name (Legal Business Name): MICAELA ALEXANDRA SEVERANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S GILBERT ST
ANAHEIM CA
92804-5230
US

IV. Provider business mailing address

2705 W ORANGE AVE
ANAHEIM CA
92804-3298
US

V. Phone/Fax

Practice location:
  • Phone: 714-527-5143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: