Provider Demographics
NPI:1063957462
Name:STEWART, LETITIA (MA60717156)
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MA60717156
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 F ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2320
Mailing Address - Country:US
Mailing Address - Phone:360-281-5168
Mailing Address - Fax:
Practice Address - Street 1:3407 F ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2320
Practice Address - Country:US
Practice Address - Phone:360-281-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT167337111NR0400X
WAMA60717156225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No111NR0400XChiropractic ProvidersChiropractorRehabilitation