Provider Demographics
NPI:1871157685
Name:SEVERNS, BRIAN (RADT R1344310419)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SEVERNS
Suffix:
Gender:M
Credentials:RADT R1344310419
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2007
Mailing Address - Country:US
Mailing Address - Phone:408-538-0893
Mailing Address - Fax:
Practice Address - Street 1:2218 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2007
Practice Address - Country:US
Practice Address - Phone:408-538-0893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1344310419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)