Provider Demographics
NPI:1245018498
Name:SWENSON, GARY (MA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SWENSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 MACKS MTN RD
Mailing Address - Street 2:
Mailing Address - City:WEST DANVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05873-9747
Mailing Address - Country:US
Mailing Address - Phone:802-424-6846
Mailing Address - Fax:
Practice Address - Street 1:5112 MACKS MTN RD
Practice Address - Street 2:
Practice Address - City:WEST DANVILLE
Practice Address - State:VT
Practice Address - Zip Code:05873-9747
Practice Address - Country:US
Practice Address - Phone:802-424-6846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT098.0133654103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis