Provider Demographics
NPI:1174712343
Name:SWAN, SALLY JEAN (L-MSW)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:JEAN
Last Name:SWAN
Suffix:
Gender:F
Credentials:L-MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CRYSTAL BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-1907
Mailing Address - Country:US
Mailing Address - Phone:631-874-1006
Mailing Address - Fax:631-874-4777
Practice Address - Street 1:220 MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3504
Practice Address - Country:US
Practice Address - Phone:631-874-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066399-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker