Provider Demographics
NPI:1164046801
Name:SWANSON, KELLY JEAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CRYSTAL COVE AVENUE, UNIT 1
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152
Mailing Address - Country:US
Mailing Address - Phone:857-201-9571
Mailing Address - Fax:
Practice Address - Street 1:32 CRYSTAL COVE AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-2552
Practice Address - Country:US
Practice Address - Phone:857-201-9571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst