Provider Demographics
NPI:1508258302
Name:SWANSON, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:1826 E PLATTE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5738
Mailing Address - Country:US
Mailing Address - Phone:719-641-4917
Mailing Address - Fax:719-418-3728
Practice Address - Street 1:1826 E PLATTE AVE STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5738
Practice Address - Country:US
Practice Address - Phone:719-641-4917
Practice Address - Fax:719-418-3728
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB 7020101YA0400X
CO09923464101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000152892Medicaid
CO1972927176OtherAGENCY NPI