Provider Demographics
NPI:1275987281
Name:SWANSON, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
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 1:22552 RESTFUL LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3375
Mailing Address - Country:US
Mailing Address - Phone:573-855-9324
Mailing Address - Fax:
Practice Address - Street 1:22552 RESTFUL LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3375
Practice Address - Country:US
Practice Address - Phone:573-855-9324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X, 103TC1900X
MO101Y00000X, 101YM0800X, 103TC2200X, 103TF0000X, 103TH0100X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No171M00000XOther Service ProvidersCase Manager/Care Coordinator