Healthcare Provider Details

I. General information

NPI: 1386501344
Provider Name (Legal Business Name): SEVERINE CORYLUS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W STATE ST
ITHACA NY
14850-5474
US

IV. Provider business mailing address

127 W STATE ST
ITHACA NY
14850-5474
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-7494
  • Fax: 607-273-7484
Mailing address:
  • Phone: 607-273-7494
  • Fax: 607-273-7484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123843
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: