Provider Demographics
NPI:1619008687
Name:SWANSON, LARRY (LMP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY STE 1658
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1729
Mailing Address - Country:US
Mailing Address - Phone:206-624-6255
Mailing Address - Fax:206-260-9081
Practice Address - Street 1:509 OLIVE WAY STE 1658
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1729
Practice Address - Country:US
Practice Address - Phone:206-624-6255
Practice Address - Fax:206-260-9081
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist