Healthcare Provider Details

I. General information

NPI: 1164046801
Provider Name (Legal Business Name): KELLY JEAN SWANSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 CRYSTAL COVE AVE UNIT 1
WINTHROP MA
02152-2552
US

IV. Provider business mailing address

32 CRYSTAL COVE AVENUE, UNIT 1
WINTHROP MA
02152
US

V. Phone/Fax

Practice location:
  • Phone: 857-201-9571
  • Fax:
Mailing address:
  • Phone: 857-201-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: