Provider Demographics
NPI:1578530861
Name:SWAN, WANDA (PT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:LOWERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 15422
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-2122
Mailing Address - Country:US
Mailing Address - Phone:912-659-8099
Mailing Address - Fax:912-257-7315
Practice Address - Street 1:37 W FAIRMONT AVE STE 321
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3459
Practice Address - Country:US
Practice Address - Phone:912-659-8099
Practice Address - Fax:912-257-7315
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-05
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0062992251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000944501CMedicaid
GA000944501AMedicaid
GA000944501EMedicaid
GA000944501GMedicaid