Provider Demographics
NPI:1730117433
Name:SWANSON, GREG SWAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:SWAN
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 1:103 RIDGE BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22610-2372
Mailing Address - Country:US
Mailing Address - Phone:706-284-7203
Mailing Address - Fax:
Practice Address - Street 1:103 RIDGE BROOK LN
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:VA
Practice Address - Zip Code:22610-2372
Practice Address - Country:US
Practice Address - Phone:706-284-7203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000604103TC2200X
VA0810008076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00383523CMedicaid
GA00383523CMedicaid
GA68BBDGJMedicare UPIN