Provider Demographics
NPI:1487075651
Name:SWANSON, MAHOGANY LOIS
Entity type:Individual
Prefix:
First Name:MAHOGANY
Middle Name:LOIS
Last Name:SWANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERQUIST DR. STE 1
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-5972
Mailing Address - Fax:
Practice Address - Street 1:2200 BERQUIST DR. STE 1
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-5972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1239346103TS0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool