Provider Demographics
NPI:1487653903
Name:SWANSON, LAURA L (OT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:SWANSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:765 N KELLOGG ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2875
Mailing Address - Country:US
Mailing Address - Phone:309-343-3434
Mailing Address - Fax:309-343-3456
Practice Address - Street 1:765 N KELLOGG ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2875
Practice Address - Country:US
Practice Address - Phone:309-343-3434
Practice Address - Fax:309-343-3456
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056002969225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146672Medicare ID - Type Unspecified