Basic Information
| Provider Information | |||||||||
| NPI: | 1912955378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWINDEMAN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR BCP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIANA | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | 2193221414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31001495A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200716000A | 05 | IN | MEDICAID | 200645500 | 05 | IN | MEDICAID |