Provider Demographics
NPI:1720579501
Name:SWENSON, ALISSA (RBT, CCM, CSW)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:SWENSON
Suffix:
Gender:F
Credentials:RBT, CCM, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 S OREM BLVD
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6979
Mailing Address - Country:US
Mailing Address - Phone:801-875-2892
Mailing Address - Fax:
Practice Address - Street 1:90 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-752-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-28
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 175T00000X
UT12158277-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1720579501Medicaid