Provider Demographics
NPI:1922553650
Name:SWAIN, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:SWAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 LAS PALMAS AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2644
Mailing Address - Country:US
Mailing Address - Phone:510-556-4544
Mailing Address - Fax:
Practice Address - Street 1:133 LAS PALMAS AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2644
Practice Address - Country:US
Practice Address - Phone:510-556-4544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist