Provider Demographics
NPI:1083124077
Name:SWAN, KELLY ANN (CADC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SWAN
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-1001
Mailing Address - Country:US
Mailing Address - Phone:702-383-4044
Mailing Address - Fax:702-385-3881
Practice Address - Street 1:930 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-1001
Practice Address - Country:US
Practice Address - Phone:702-383-4044
Practice Address - Fax:702-385-3881
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00370-C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)