Provider Demographics
NPI:1033546841
Name:SWANSON, MARIE KOLEKA
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:KOLEKA
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:KOLEKA
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8200 HOMER DR STE F
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-3330
Mailing Address - Country:US
Mailing Address - Phone:907-345-0050
Mailing Address - Fax:907-344-5103
Practice Address - Street 1:8200 HOMER DR STE F
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-3330
Practice Address - Country:US
Practice Address - Phone:907-345-0050
Practice Address - Fax:907-344-5103
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2698225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK536OtherSTATE OF ALASKA OT LICENSE