Provider Demographics
NPI:1043633159
Name:SWAN, GARY (MSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SWAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1220
Mailing Address - Country:US
Mailing Address - Phone:414-540-2170
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-446-9981
Practice Address - Fax:262-446-9983
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8083-1231041C0700X
WI15662-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)