Provider Demographics
NPI:1841207339
Name:SWANSON, ROBERT J (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
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 1:1009 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1405
Mailing Address - Country:US
Mailing Address - Phone:708-848-6808
Mailing Address - Fax:
Practice Address - Street 1:1009 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1405
Practice Address - Country:US
Practice Address - Phone:708-848-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001672820OtherBCBS PROVIDER #
IL0001672820OtherBCBS PROVIDER #