Basic Information
| Provider Information | |||||||||
| NPI: | 1710960331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWENBY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 E PIONEER AVE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983723265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534458120 | ||||||||
| FaxNumber: | 2536973730 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 E. PIONEER AVE. | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534458120 | ||||||||
| FaxNumber: | 2536973730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301073554 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD00048030 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8494197 | 05 | WA | MEDICAID | 4079420 | 05 | MI | MEDICAID |