Provider Demographics
NPI:1922169762
Name:SWANSON, ANDREA JO (MS QMHP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JO
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MS QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 N TALMAN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647
Mailing Address - Country:US
Mailing Address - Phone:773-486-5260
Mailing Address - Fax:
Practice Address - Street 1:6415 STANLEY
Practice Address - Street 2:ILC ENTERPRISES
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-788-0511
Practice Address - Fax:708-788-0831
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker