Provider Demographics
NPI:1942073770
Name:SWANSON, STACIA N (MA, PPC)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:N
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MA, PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 W 38TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4765
Mailing Address - Country:US
Mailing Address - Phone:308-641-9885
Mailing Address - Fax:
Practice Address - Street 1:136 W 21ST AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-2721
Practice Address - Country:US
Practice Address - Phone:307-532-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health