Provider Demographics
NPI:1124039367
Name:SWANSON, TIMOTHY (MS, LCPC, LPC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MS, LCPC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 1/2 W GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1722
Mailing Address - Country:US
Mailing Address - Phone:262-723-3424
Mailing Address - Fax:262-723-8308
Practice Address - Street 1:1 1/2 W GENEVA ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1722
Practice Address - Country:US
Practice Address - Phone:262-723-3424
Practice Address - Fax:262-723-8308
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5120-125101YP2500X
IL180-000950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124039367Medicaid
IL5615096OtherBC/BS OF AMERICA