Provider Demographics
NPI:1225854128
Name:STEWART, VANESSA KELLY
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:KELLY
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 1:8931 CR 622
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-7896
Mailing Address - Country:US
Mailing Address - Phone:863-661-8130
Mailing Address - Fax:
Practice Address - Street 1:8931 CR 622
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-7896
Practice Address - Country:US
Practice Address - Phone:863-661-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health