Provider Demographics
NPI:1821359324
Name:SWANSON, ROBERT LYLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYLE
Last Name:SWANSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1026
Mailing Address - Country:US
Mailing Address - Phone:618-874-3597
Mailing Address - Fax:618-874-8212
Practice Address - Street 1:5050 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1026
Practice Address - Country:US
Practice Address - Phone:618-874-3597
Practice Address - Fax:618-874-8212
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001811224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant