Healthcare Provider Details

I. General information

NPI: 1710481262
Provider Name (Legal Business Name): AMBER KAY SWANSON LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 ANDERSON AVE
SAINT CLOUD MN
56303-2048
US

IV. Provider business mailing address

713 ANDERSON AVE
SAINT CLOUD MN
56303-2048
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-3760
  • Fax: 320-229-3763
Mailing address:
  • Phone: 320-229-3760
  • Fax: 320-229-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302262
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number402262
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: