Provider Demographics
NPI:1366721847
Name:SWINDELLS, STEPHEN CRAIG (LADC 1)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CRAIG
Last Name:SWINDELLS
Suffix:
Gender:M
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 APPLETON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2515
Mailing Address - Country:US
Mailing Address - Phone:978-319-3325
Mailing Address - Fax:978-459-9136
Practice Address - Street 1:102 APPLETON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2515
Practice Address - Country:US
Practice Address - Phone:978-319-3325
Practice Address - Fax:978-459-9136
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA978324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA02261995Medicaid