Healthcare Provider Details

I. General information

NPI: 1821372186
Provider Name (Legal Business Name): NICOLE M. SWANSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S MERAMEC AVE
SAINT LOUIS MO
63105-1711
US

IV. Provider business mailing address

9416 LAVERN PL
SAINT LOUIS MO
63123-4536
US

V. Phone/Fax

Practice location:
  • Phone: 314-615-0400
  • Fax:
Mailing address:
  • Phone: 314-471-5208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2008029731
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: