MEDICARE: BRENDA SEVERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	3087	ND

General Provider Information

NPI Number	:	1134538770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA SEVERSON

Provider Business Mailing Address
First Line	:	1820 WALNUT ST E STE 5
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-3411
Country	:	US
Telephone Number	:	701-662-4913
Fax Number	:	701-662-4963

Provider Business Practice Location Address
First Line	:	1820 WALNUT ST E STE 5
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-3411
Country	:	US
Telephone Number	:	701-662-4913
Fax Number	:	701-662-4963

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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Directions to “ BRENDA SEVERSON ” Practice Location

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