Provider Demographics
NPI:1720271539
Name:SWAN EXPRESSIVE THERAPIES
Entity Type:Organization
Organization Name:SWAN EXPRESSIVE THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PROF COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARA
Authorized Official - Middle Name:RITA
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA LCPC ATR-BC
Authorized Official - Phone:443-326-5041
Mailing Address - Street 1:260 GATEWAY DR
Mailing Address - Street 2:BUILDING 1 SUITE 15B
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4268
Mailing Address - Country:US
Mailing Address - Phone:443-326-5041
Mailing Address - Fax:
Practice Address - Street 1:6731 YOUNGSTOWN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-1026
Practice Address - Country:US
Practice Address - Phone:443-326-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC 1896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty