Provider Demographics
NPI:1699095935
Name:STEWART, AUDREY (PT, DPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775-2 LAKE WATERFORD WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7213
Practice Address - Country:US
Practice Address - Phone:321-255-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT255252251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics