Provider Demographics
NPI:1831345446
Name:SWANSON, MARIJANE (COTA/C)
Entity type:Individual
Prefix:
First Name:MARIJANE
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:COTA/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 ADAMS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4865
Mailing Address - Country:US
Mailing Address - Phone:714-556-2288
Mailing Address - Fax:714-435-1745
Practice Address - Street 1:1700 ADAMS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4865
Practice Address - Country:US
Practice Address - Phone:714-556-2288
Practice Address - Fax:714-435-1745
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA 1592224Z00000X
MD1018159224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOTA 1592OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY
MD1018159OtherNATIONAL BOARD FOR CERT IN OCCUPATIONAL THERAPY