Provider Demographics
NPI:1881630325
Name:SWARTOUT, ILYSSA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ILYSSA
Middle Name:
Last Name:SWARTOUT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19580 W INDIAN SCHOOL RD STE 105-134
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-2081
Mailing Address - Country:US
Mailing Address - Phone:602-548-1444
Mailing Address - Fax:602-548-1446
Practice Address - Street 1:18205 N 51ST AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1490
Practice Address - Country:US
Practice Address - Phone:602-548-1444
Practice Address - Fax:602-548-1446
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3612103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z78042Medicare PIN