Provider Demographics
NPI:1275241317
Name:SWANSON, MADISON MARIE (RMHCI)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 NE ACAPULCO DR
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-6657
Mailing Address - Country:US
Mailing Address - Phone:772-353-7099
Mailing Address - Fax:
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-742-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22745101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty