MEDICARE: DR. LISETTE WILCOX SWAILS PHD- LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	2396	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1841281805	OTHER	KS	CENTER NPI

General Provider Information

NPI Number	:	1194004481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISETTE WILCOX SWAILS PHD- LP

Provider Business Mailing Address
First Line	:	3903 RAINBOW BLVD
Second Line	:	KUMC-CCHD MS 4003
City	:	KANSAS CITY
State	:	KS
Zip	:	66103-2917
Country	:	US
Telephone Number	:	913-588-5922
Fax Number	:

Provider Business Practice Location Address
First Line	:	3903 RAINBOW BLVD
Second Line	:	KUMC-CCHD MS 4003
City	:	KANSAS CITY
State	:	KS
Zip	:	66103-2917
Country	:	US
Telephone Number	:	913-588-5922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	02/11/2016

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