Individual
MELISSA B SEVERANCE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA LP
Contact information
Practice address
11550 STILLWATER BLVD N STE 102, LAKE ELMO, MN 55042-8613
(651) 777-3336
Mailing address
11550 STILLWATER BLVD N STE 102, LAKE ELMO, MN 55042-8613
(651) 777-3336
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP3637
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
41D04SE
BCBS GROUP NUMBER
MN
01
—
41D05SE
BCBS INDIVIDUAL PROVIDER
MN
01
—
6292882
MEDICA ID
MN
Enumeration date
12/28/2006
Last updated
07/08/2007
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