Healthcare Provider Details

I. General information

NPI: 1235542986
Provider Name (Legal Business Name): CHEYENNE SEVERENCE MSW LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 E BROAD ST
COLUMBUS OH
43205-1156
US

IV. Provider business mailing address

200 BUCKEYE CIR
COLUMBUS OH
43217-1000
US

V. Phone/Fax

Practice location:
  • Phone: 614-928-9418
  • Fax: 614-928-9401
Mailing address:
  • Phone: 614-928-9418
  • Fax: 614-928-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1303046
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: