Provider Demographics
NPI:1629511555
Name:FUNCTIONAL LIVING
Entity Type:Organization
Organization Name:FUNCTIONAL LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:678-773-9564
Mailing Address - Street 1:PO BOX 6826
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-0826
Mailing Address - Country:US
Mailing Address - Phone:678-773-9564
Mailing Address - Fax:
Practice Address - Street 1:305 DUNWOODY CHACE
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4587
Practice Address - Country:US
Practice Address - Phone:678-773-9564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006296225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty