MEDICARE: MRS. VICTORIA MARIA FLEMING SEVERNS

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	235Z00000X	Speech-Language Pathologist	15569	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15569	OTHER	TX	TX DEPT OF STATE HEALTH

General Provider Information

NPI Number	:	1326015439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICTORIA MARIA FLEMING SEVERNS

Provider Business Mailing Address
First Line	:	2613 SYLVANGLEN ST
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-2221
Country	:	US
Telephone Number	:	817-447-0313
Fax Number	:

Provider Business Practice Location Address
First Line	:	4763 BARWICK DR
Second Line	:	OVERTON SPEECH AND LANGUAGE CENTER
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1531
Country	:	US
Telephone Number	:	817-294-8408
Fax Number	:	817-294-8411

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

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	07/08/2007

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