Provider Demographics
NPI:1356493555
Name:SWENSON, GREG G (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:G
Last Name:SWENSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 KANSAS CITY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4105
Mailing Address - Country:US
Mailing Address - Phone:605-341-5436
Mailing Address - Fax:605-721-5436
Practice Address - Street 1:929 KANSAS CITY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4105
Practice Address - Country:US
Practice Address - Phone:605-341-5436
Practice Address - Fax:605-721-5436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD223103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550052Medicaid
SD6550052Medicaid
SDR02596Medicare UPIN