Provider Demographics
NPI:1659690428
Name:SWANSON, JOHN LEROY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEROY
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 SW MADISON AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4728
Mailing Address - Country:US
Mailing Address - Phone:541-752-2689
Mailing Address - Fax:
Practice Address - Street 1:260 SW MADISON AVE STE 107
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4728
Practice Address - Country:US
Practice Address - Phone:541-752-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional