Provider Demographics
NPI:1932800935
Name:SWANN, CLIFFORD DANIEL THOMAS
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:DANIEL THOMAS
Last Name:SWANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 PRIDDY RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-9604
Mailing Address - Country:US
Mailing Address - Phone:706-885-2881
Mailing Address - Fax:
Practice Address - Street 1:1805 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3871
Practice Address - Country:US
Practice Address - Phone:706-710-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA10782225200000X
GAPTA004873225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant