Provider Demographics
NPI:1124190988
Name:SWANSON, RICHARD TODD (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:TODD
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1640
Mailing Address - Country:US
Mailing Address - Phone:631-363-8646
Mailing Address - Fax:631-363-8313
Practice Address - Street 1:60 WILSON ST
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1640
Practice Address - Country:US
Practice Address - Phone:631-363-8646
Practice Address - Fax:631-363-8313
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist