Provider Demographics
NPI:1588728588
Name:SWENSEN, SAMANTHA SWENSEN (MS)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:SWENSEN
Last Name:SWENSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:SWENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTRL
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:2915 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005129225XP0200X
AZ5129225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ692646Medicaid
AZZ155549OtherMEDICARE PTAN