Provider Demographics
NPI:1578673380
Name:SWAN, RONALD MARTIN (MS)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:MARTIN
Last Name:SWAN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:KAISER PERMANENTE INTERSTATE MEDICAL OFFICE E
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1043
Mailing Address - Country:US
Mailing Address - Phone:503-249-5275
Mailing Address - Fax:503-249-5508
Practice Address - Street 1:3550 N. INTERSTATE AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1043
Practice Address - Country:US
Practice Address - Phone:503-285-9321
Practice Address - Fax:503-249-5508
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR CO947101YA0400X
WAWA LH00004068101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health