Basic Information
| Provider Information | |||||||||
| NPI: | 1982655676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWIERC | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BANK ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BANK ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 342 | MT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0061997 | 05 | MT | MEDICAID | 52691 | 01 | MT | BCBS | OTHER |