Provider Demographics
NPI:1982336509
Name:STEWARD, KENNEDY
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:STEWARD
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-0458
Mailing Address - Country:US
Mailing Address - Phone:616-889-0173
Mailing Address - Fax:
Practice Address - Street 1:321 E LAKE ST STE 7
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2459
Practice Address - Country:US
Practice Address - Phone:231-431-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022272101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health