Provider Demographics
NPI:1164532875
Name:SWANSON-WHITWORTH, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SWANSON-WHITWORTH
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 1:113 BERG CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MO
Mailing Address - Zip Code:63332-1544
Mailing Address - Country:US
Mailing Address - Phone:636-482-4144
Mailing Address - Fax:
Practice Address - Street 1:3501 DUNN RD
Practice Address - Street 2:STE 108
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6762
Practice Address - Country:US
Practice Address - Phone:314-839-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102025OtherLICENSE #