Provider Demographics
NPI:1740976182
Name:SWENSEN-GORDON, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SWENSEN-GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28026 STATE HIGHWAY 44
Mailing Address - Street 2:
Mailing Address - City:SHINGLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:96088-9673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28026 STATE HIGHWAY 44
Practice Address - Street 2:
Practice Address - City:SHINGLETOWN
Practice Address - State:CA
Practice Address - Zip Code:96088-9673
Practice Address - Country:US
Practice Address - Phone:530-604-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician