Provider Demographics
NPI:1588717342
Name:STEWART, AMY RENAE (OTRL)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:RENAE
Last Name:STEWART
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3981 WOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5495
Mailing Address - Country:US
Mailing Address - Phone:575-442-9023
Mailing Address - Fax:
Practice Address - Street 1:3101 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-9713
Practice Address - Country:US
Practice Address - Phone:575-434-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1697225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG9058Medicaid