Provider Demographics
NPI:1194135046
Name:SWAN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 SOUND BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-1626
Mailing Address - Country:US
Mailing Address - Phone:203-698-2965
Mailing Address - Fax:
Practice Address - Street 1:296 SOUND BEACH AVE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1626
Practice Address - Country:US
Practice Address - Phone:203-698-2965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005132225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist