Provider Demographics
NPI:1386795839
Name:SWAN, EARNESTINE MANGANA (IMF)
Entity type:Individual
Prefix:MS
First Name:EARNESTINE
Middle Name:MANGANA
Last Name:SWAN
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 LAKESIDE DR APT 201
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4342
Mailing Address - Country:US
Mailing Address - Phone:510-836-1024
Mailing Address - Fax:
Practice Address - Street 1:1445 LAKESIDE DR APT 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-4342
Practice Address - Country:US
Practice Address - Phone:510-836-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health