Provider Demographics
NPI:1174196661
Name:SWAN, KATELYN MARIE (LCSWA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SWAN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST BEND
Mailing Address - State:NC
Mailing Address - Zip Code:27018-7971
Mailing Address - Country:US
Mailing Address - Phone:336-406-5052
Mailing Address - Fax:
Practice Address - Street 1:3637 OLD VINEYARD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4842
Practice Address - Country:US
Practice Address - Phone:336-794-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0164951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical