Provider Demographics
NPI:1104957307
Name:SEVERSON, CAROL A (LDM,CPM)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:LDM,CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 SANTIAM HWY SE
Mailing Address - Street 2:PMB 314
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-5211
Mailing Address - Country:US
Mailing Address - Phone:541-928-1002
Mailing Address - Fax:541-327-2721
Practice Address - Street 1:1209 SHORTRIDGE ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6934
Practice Address - Country:US
Practice Address - Phone:541-928-1002
Practice Address - Fax:541-327-2721
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD102953176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR140058Medicaid
OR98040016OtherNARM
ORLDM-LD 102953OtherHEALTH LICENSING BOARD