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General NPI Number Information
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NPI Number | 1629309125
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Entity Type | Individual
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Provider Name | KELLY F SEVERSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/22/2010
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Last Update Date | 01/22/2010
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Provider Practice Location Address
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Address Line | 2017 JEFFERSON ST SW
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City | ROANOKE
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State | VA
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Zip | 24014-2419
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Country | US
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Telephone | 540-853-0900
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Fax | 540-853-0518
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Provider Business Mailing Address
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Address Line | 213 S JEFFERSON ST SUITE 625
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City | ROANOKE
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State | VA
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Zip | 24011-1700
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Country | US
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Telephone | 540-224-5681
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Fax | 540-224-5684
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904007302
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License Number State | VA
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