Healthcare Provider Details

I. General information

NPI: 1639271687
Provider Name (Legal Business Name): GERALD C SWANSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GERRY C SWANSON LCSW

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 CARLISLE BLVD NE STE 210
ALBUQUERQUE NM
87107-4856
US

IV. Provider business mailing address

4308 CARLISLE BLVD NE STE 210
ALBUQUERQUE NM
87107-4856
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1921
  • Fax: 505-247-1020
Mailing address:
  • Phone: 505-247-1921
  • Fax: 505-247-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-0195
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: