Provider Demographics
NPI:1427328251
Name:SEVERINE, MARIANNE (PT)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:SEVERINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 N ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61531-1059
Mailing Address - Country:US
Mailing Address - Phone:309-245-2970
Mailing Address - Fax:
Practice Address - Street 1:701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61531-1460
Practice Address - Country:US
Practice Address - Phone:309-245-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.013261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist