Healthcare Provider Details

I. General information

NPI: 1003753252
Provider Name (Legal Business Name): GWENDOLYN KAY SEVERANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15805 S BUDLONG AVE
GARDENA CA
90247-4303
US

IV. Provider business mailing address

333 S BEAUDRY AVE FL 17
LOS ANGELES CA
90017-5105
US

V. Phone/Fax

Practice location:
  • Phone: 310-965-7906
  • Fax:
Mailing address:
  • Phone: 310-965-7906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: