Provider Demographics
NPI:1811109432
Name:SWANSON, ANITA LOUISE (PT)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:LOUISE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ANITA
Other - Middle Name:SWANSON
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:111 PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840
Mailing Address - Country:US
Mailing Address - Phone:304-640-1019
Mailing Address - Fax:304-574-3643
Practice Address - Street 1:111 FAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840
Practice Address - Country:US
Practice Address - Phone:304-574-1176
Practice Address - Fax:304-574-3643
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV731225100000X
MN2578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156354000Medicaid