Provider Demographics
NPI:1790111367
Name:SWAIN, ELISE (CPMT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:SWAIN
Suffix:
Gender:F
Credentials:CPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MIRADOR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612
Mailing Address - Country:US
Mailing Address - Phone:949-854-5555
Mailing Address - Fax:
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:STE. 810
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-854-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABT30007599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist