Basic Information
| Provider Information | |||||||||
| NPI: | 1821039744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWAN | ||||||||
| FirstName: | DAINETT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW #53011 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWAN | ||||||||
| OtherFirstName: | DAINETT | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW #27352 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343700 | ||||||||
| FaxNumber: | 2109220162 | ||||||||
| Practice Location | |||||||||
| Address1: | 5542 WALZEM RD | ||||||||
| Address2: | |||||||||
| City: | WINDCREST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782182103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106372450 | ||||||||
| FaxNumber: | 2105901380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW #27352 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 53011 | TX | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 002648300 | 05 | ID | MEDICAID | 7644813 | 01 | ID | AETNA | OTHER | 000010155033 | 01 | ID | BLUE SHIELD | OTHER | L5906 | 01 | ID | BLUE CROSS | OTHER |