Provider Demographics
NPI:1679676050
Name:SWANSON, GARY A (LCPC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:A
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-3503
Mailing Address - Country:US
Mailing Address - Phone:207-594-0226
Mailing Address - Fax:
Practice Address - Street 1:66 CHAPMAN ST
Practice Address - Street 2:SUITE E
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4614
Practice Address - Country:US
Practice Address - Phone:207-563-3022
Practice Address - Fax:207-563-3022
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1868101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1700996063Medicare UPIN
MEPENDINGMedicare ID - Type UnspecifiedCOUNSELOR MENTAL HEALTH