Provider Demographics
NPI:1346742616
Name:SWANSON, CONNOR VERNON (OTD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:VERNON
Last Name:SWANSON
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W SAINT JOHN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6583
Mailing Address - Country:US
Mailing Address - Phone:602-579-6374
Mailing Address - Fax:
Practice Address - Street 1:521 W SAINT JOHN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023
Practice Address - Country:US
Practice Address - Phone:602-579-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician