Provider Demographics
NPI:1538740519
Name:SWAIN, MARYGRACE C (RBT)
Entity type:Individual
Prefix:
First Name:MARYGRACE
Middle Name:C
Last Name:SWAIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 SPRING PARK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5989
Mailing Address - Country:US
Mailing Address - Phone:904-666-5147
Mailing Address - Fax:
Practice Address - Street 1:5600 SPRING PARK RD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5989
Practice Address - Country:US
Practice Address - Phone:904-666-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104990300Medicaid