Provider Demographics
NPI:1124843487
Name:BLACK, STEWART (BCBA)
Entity type:Individual
Prefix:
First Name:STEWART
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 4TH AVE SE STE 300
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-1844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:866-496-4073
Practice Address - Street 1:502 MARKET ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-1411
Practice Address - Country:US
Practice Address - Phone:402-713-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1-24-71224103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst