Basic Information
Provider Information | |||||||||
NPI: | 1467572636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SWAN | ||||||||
FirstName: | ANN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LLP, CAAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 428 | ||||||||
Address2: | 1555 INDUSTRIAL DR. | ||||||||
City: | OWOSSO | ||||||||
State: | MI | ||||||||
PostalCode: | 488670428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897236791 | ||||||||
FaxNumber: | 9897255061 | ||||||||
Practice Location | |||||||||
Address1: | 1555 INDUSTRIAL DR | ||||||||
Address2: | SCCMHA | ||||||||
City: | OWOSSO | ||||||||
State: | MI | ||||||||
PostalCode: | 488679775 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897236791 | ||||||||
FaxNumber: | 9897255061 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2007 | ||||||||
LastUpdateDate: | 01/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 101357 | MI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | 6301008819 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.