Provider Demographics
NPI:1578663688
Name:SWAN, ALICIA ANN (MPT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:SWAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 CAMINO DOS RIOS STE 406
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-1156
Mailing Address - Country:US
Mailing Address - Phone:805-375-1461
Mailing Address - Fax:805-498-7613
Practice Address - Street 1:2814 CAMINO DOS RIOS STE 406
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-1156
Practice Address - Country:US
Practice Address - Phone:805-375-1461
Practice Address - Fax:805-498-7613
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWPT26132A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26132AOtherP.T. L:ICENSE
CAP38324Medicare UPIN
CAW15558Medicare ID - Type Unspecified