Provider Demographics
NPI:1265193940
Name:SWAN, AMY NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:SWAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:NANGAUTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4780 JASMINE DR
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-2320
Mailing Address - Country:US
Mailing Address - Phone:817-896-9632
Mailing Address - Fax:682-885-7532
Practice Address - Street 1:4780 JASMINE DR
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-2320
Practice Address - Country:US
Practice Address - Phone:817-896-9632
Practice Address - Fax:682-885-7532
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX564481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical