Basic Information
| Provider Information | |||||||||
| NPI: | 1801846415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWENSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567026 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 ANDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202293761 | ||||||||
| FaxNumber: | 3202293763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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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 | 2084A0401X | 26476 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 665323500 | 05 | MN | MEDICAID |