Provider Demographics
NPI:1154958684
Name:STEWART, CHARELLE
Entity type:Individual
Prefix:
First Name:CHARELLE
Middle Name:
Last Name:STEWART
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 1:4545 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-3045
Mailing Address - Country:US
Mailing Address - Phone:301-609-6900
Mailing Address - Fax:301-934-1234
Practice Address - Street 1:4545 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3045
Practice Address - Country:US
Practice Address - Phone:301-609-6900
Practice Address - Fax:301-934-1234
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT1919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty