Provider Demographics
NPI:1477154052
Name:SWANSON, MARK T
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:SWANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 FREMONT AVE # 1382
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-7001
Mailing Address - Country:US
Mailing Address - Phone:626-253-5494
Mailing Address - Fax:
Practice Address - Street 1:2021 SPERRY AVE STE 44
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7417
Practice Address - Country:US
Practice Address - Phone:626-344-9409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 104100000X
CA1160151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker