Provider Demographics
NPI:1912744889
Name:STEWART, ELISSA ANNE
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:ANNE
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 1:180 CENTER PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8859
Mailing Address - Country:US
Mailing Address - Phone:904-342-7103
Mailing Address - Fax:
Practice Address - Street 1:180 CENTER PLACE WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8859
Practice Address - Country:US
Practice Address - Phone:904-342-7103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician