Provider Demographics
NPI:1992939052
Name:ADOLPHUS, SEVERIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:SEVERIA
Middle Name:
Last Name:ADOLPHUS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31235 HARPER AVE STE 244
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1425
Mailing Address - Country:US
Mailing Address - Phone:313-915-9138
Mailing Address - Fax:
Practice Address - Street 1:31235 HARPER AVE STE 244
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1425
Practice Address - Country:US
Practice Address - Phone:313-334-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MI4704170742364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult