Basic Information
| Provider Information | |||||||||
| NPI: | 1033290770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWENSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | X | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 EAST FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284404 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 N 25TH ST E | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153928216 | ||||||||
| FaxNumber: | 7153926055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 05/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 746 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 286047300 | 05 | MN | MEDICAID | 39048500 | 05 | WI | MEDICAID |