Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 2012175 | TX |
NPI | 1376024885 |
---|---|
Provider Name | Denise Diane Swanson |
First Address | Gilmer, TX 75645-3915 |
Second Address | Gilmer, TX 75645-3915 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2018 |
Last Update Date | 22/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2012175 | PTA LICENSE (01) | TX |