Provider Demographics
NPI:1932346111
Name:SWAN, SALLY M (LAC)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:M
Last Name:SWAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5003
Mailing Address - Country:US
Mailing Address - Phone:503-552-1933
Mailing Address - Fax:503-257-5929
Practice Address - Street 1:2220 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5003
Practice Address - Country:US
Practice Address - Phone:503-552-1933
Practice Address - Fax:503-257-5929
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01252171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist