Provider Demographics
NPI:1114692290
Name:SWANSON, MYKAYLA (RADT)
Entity Type:Individual
Prefix:
First Name:MYKAYLA
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 LOCHMOOR DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8506
Mailing Address - Country:US
Mailing Address - Phone:951-666-9147
Mailing Address - Fax:
Practice Address - Street 1:20331 FLANAGAN ROAD
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1436150621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)