Provider Demographics
NPI:1619483732
Name:MARY BETH SWANSON LCSW LLC
Entity Type:Organization
Organization Name:MARY BETH SWANSON LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:970-581-5155
Mailing Address - Street 1:3306 DUNBAR AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2356
Mailing Address - Country:US
Mailing Address - Phone:970-581-5155
Mailing Address - Fax:
Practice Address - Street 1:209 E PLUM ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3442
Practice Address - Country:US
Practice Address - Phone:970-581-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO009923131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000148097Medicaid