Healthcare Provider Details

I. General information

NPI: 1689678591
Provider Name (Legal Business Name): SUSAN ELIZABETH SWANN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 W BRENDA LOOP
FLAGSTAFF AZ
86001-0916
US

IV. Provider business mailing address

PO BOX 1569
FLAGSTAFF AZ
86002-1569
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-0922
  • Fax: 928-214-0915
Mailing address:
  • Phone: 928-214-0922
  • Fax: 928-214-0915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1520
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: