Provider Demographics
NPI:1932224185
Name:SWANSEY, MICAH K SR (PSYD)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:K
Last Name:SWANSEY
Suffix:SR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 GLEN EAGLES DR
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1160
Mailing Address - Country:US
Mailing Address - Phone:708-259-8154
Mailing Address - Fax:708-747-1038
Practice Address - Street 1:593 BURNHAM AVENUE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409
Practice Address - Country:US
Practice Address - Phone:708-832-1002
Practice Address - Fax:708-832-1099
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006944103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212915Medicare ID - Type Unspecified