Provider Demographics
NPI:1902185796
Name:SWANSON, MELISSA (PHD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 QUAIL LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9389
Mailing Address - Country:US
Mailing Address - Phone:323-630-2129
Mailing Address - Fax:
Practice Address - Street 1:7080 QUAIL LAKES DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9389
Practice Address - Country:US
Practice Address - Phone:323-630-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6774103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist