Provider Demographics
NPI:1386694909
Name:STEWART, STEPHANIE (LLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 LOVERS LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1572
Mailing Address - Country:US
Mailing Address - Phone:269-343-3010
Mailing Address - Fax:269-343-3017
Practice Address - Street 1:5148 LOVERS LN
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1572
Practice Address - Country:US
Practice Address - Phone:269-343-3010
Practice Address - Fax:269-343-3017
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361002804103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP108927600OtherBCBSM