Provider Demographics
NPI:1588869747
Name:SEVERSON, TRACY R (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:R
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:OHSU MAIL CODE: UHS 18
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-6160
Mailing Address - Fax:503-494-3769
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:OHSU MAIL CODE: UHS 18
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6160
Practice Address - Fax:503-494-3769
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered