Provider Demographics
NPI:1952433047
Name:SWAN, KIMBERLY ANNE (MSED NCC LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:SWAN
Suffix:
Gender:F
Credentials:MSED NCC LMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 PATTERSON ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:
Practice Address - Street 1:1519 NYE ROAD
Practice Address - Street 2:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000211101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249154Medicaid