Basic Information
| Provider Information | |||||||||
| NPI: | 1831345446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | MARIJANE | ||||||||
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| Credential: | COTA/C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 ADAMS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926264865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145562288 | ||||||||
| FaxNumber: | 7144351745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 ADAMS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926264865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145562288 | ||||||||
| FaxNumber: | 7144351745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2008 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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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 | 224Z00000X | OTA 1592 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 1018159 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | OTA 1592 | 01 | CA | CALIFORNIA BOARD OF OCCUPATIONAL THERAPY | OTHER | 1018159 | 01 | MD | NATIONAL BOARD FOR CERT IN OCCUPATIONAL THERAPY | OTHER |