Provider Demographics
NPI:1710558945
Name:SWANSON, KRISTYN
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5564 S US HIGHWAY 421
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46391-9722
Mailing Address - Country:US
Mailing Address - Phone:219-608-0928
Mailing Address - Fax:
Practice Address - Street 1:2801 BERTHOLET BLVD STE 301
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7959
Practice Address - Country:US
Practice Address - Phone:219-323-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000990A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health