MEDICARE: MRS. CONNIE MARIE SWANSON MFT

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	101YP2500X	Professional Counselor	41585	CA

General Provider Information

NPI Number	:	1861547242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CONNIE MARIE SWANSON MFT

Provider Business Mailing Address
First Line	:	611 VETERANS BLVD STE 119
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-1462
Country	:	US
Telephone Number	:	650-504-4655
Fax Number	:	650-365-4566

Provider Business Practice Location Address
First Line	:	611 VETERANS BLVD STE 119
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-1462
Country	:	US
Telephone Number	:	650-504-4655
Fax Number	:	650-365-4566

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/07/2012

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