Provider Demographics
NPI:1306997010
Name:SEVERANCE, SUE LAURA (MSW)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:LAURA
Last Name:SEVERANCE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NE RICE RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5849
Mailing Address - Country:US
Mailing Address - Phone:816-966-0900
Mailing Address - Fax:
Practice Address - Street 1:5904 E BANNISTER RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-1141
Practice Address - Country:US
Practice Address - Phone:816-966-0900
Practice Address - Fax:816-347-3209
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24201041C0700X
MO0045931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080AMedicaid
KS100098080COtherSED WAIVER
KS100098080COtherSED WAIVER