Provider Demographics
NPI:1235619859
Name:SWANSON, WAYNE C (LMFTA, CDP)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:C
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LMFTA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6534 NE PLUM ST
Mailing Address - Street 2:
Mailing Address - City:SUQUAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98392-9709
Mailing Address - Country:US
Mailing Address - Phone:360-990-8655
Mailing Address - Fax:
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8330
Practice Address - Country:US
Practice Address - Phone:360-373-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WAMG60821517106H00000X
WALF61152760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMG60821517Medicaid