Basic Information
| Provider Information | |||||||||
| NPI: | 1811069990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | BILLI | ||||||||
| MiddleName: | JAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAVES | ||||||||
| OtherFirstName: | BILLI | ||||||||
| OtherMiddleName: | JAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0554111406 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 5TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572013713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057535400 | ||||||||
| FaxNumber: | 6057536208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 123POO | IA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 954-SLP | SD | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0601260 | 05 | IA | MEDICAID | 0655407 | 05 | IA | MEDICAID | 0803635 | 05 | IA | MEDICAID |