1093379802 NPI number — ARIEL E SWANSON LCSW

Table of content: ARIEL E SWANSON LCSW (NPI 1093379802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093379802 NPI number — ARIEL E SWANSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWANSON
Provider First Name:
ARIEL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POZZI
Provider Other First Name:
ARIEL
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093379802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 PARK AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61356-3903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-875-4531
Provider Business Mailing Address Fax Number:
815-876-2119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 PARK AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-875-4531
Provider Business Practice Location Address Fax Number:
815-876-2118
Provider Enumeration Date:
04/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149020435 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 149020435 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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