Healthcare Provider Details

I. General information

NPI: 1962624999
Provider Name (Legal Business Name): PAUL SEVERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10877 CONDUCTOR BLVD SUITE 300
SUTTER CREEK CA
95685-9687
US

IV. Provider business mailing address

10877 CONDUCTOR BLVD SUITE 300
SUTTER CREEK CA
95685-9687
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-6412
  • Fax:
Mailing address:
  • Phone: 209-223-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: