Provider Demographics
NPI:1255109401
Name:SWANSON, SARA JANE (SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 HERITAGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-6239
Mailing Address - Country:US
Mailing Address - Phone:815-527-1354
Mailing Address - Fax:
Practice Address - Street 1:1845 HERITAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-6239
Practice Address - Country:US
Practice Address - Phone:815-527-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist