Provider Demographics
NPI:1265316632
Name:SEVERINO, KIERSTEN
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:SEVERINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 DEADWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4204
Mailing Address - Country:US
Mailing Address - Phone:712-331-1016
Mailing Address - Fax:
Practice Address - Street 1:987 DEADWOOD LOOP
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4204
Practice Address - Country:US
Practice Address - Phone:712-331-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant