Healthcare Provider Details

I. General information

NPI: 1679581110
Provider Name (Legal Business Name): JAMES SEVERA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EAST BROADWAY
COUNCIL BLUFFS IA
51503
US

IV. Provider business mailing address

2132 S 42ND ST
OMAHA NE
68105
US

V. Phone/Fax

Practice location:
  • Phone: 712-323-4478
  • Fax: 712-323-4188
Mailing address:
  • Phone: 402-558-1858
  • Fax: 402-558-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26898
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberT-044087
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22841
License Number StateIA

VIII. Authorized Official

Name: JULIE JEAN BAILEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 402-558-1858