Provider Demographics
NPI:1902569478
Name:SWANSON, ALYSS M (REV)
Entity Type:Individual
Prefix:
First Name:ALYSS
Middle Name:M
Last Name:SWANSON
Suffix:
Gender:F
Credentials:REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8418 CHENIN BLANC LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1412
Mailing Address - Country:US
Mailing Address - Phone:408-391-4268
Mailing Address - Fax:
Practice Address - Street 1:1760 THE ALAMEDA STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1728
Practice Address - Country:US
Practice Address - Phone:408-391-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist