Provider Demographics
NPI:1770012635
Name:SWENSON, SAMANTHA ANN (MA, NCC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:SWENSON
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SILVER KNIGHT WAY # 33-106B
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-8321
Mailing Address - Country:US
Mailing Address - Phone:507-382-8006
Mailing Address - Fax:
Practice Address - Street 1:107 E MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5761
Practice Address - Country:US
Practice Address - Phone:407-930-4711
Practice Address - Fax:866-255-1576
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16048101YM0800X
FL2731106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health