Provider Demographics
NPI:1013574748
Name:STEWART, TYCE ALDEN (DPT)
Entity Type:Individual
Prefix:
First Name:TYCE
Middle Name:ALDEN
Last Name:STEWART
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1751
Mailing Address - Country:US
Mailing Address - Phone:208-785-0123
Mailing Address - Fax:208-782-1885
Practice Address - Street 1:285 W FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1751
Practice Address - Country:US
Practice Address - Phone:208-785-0123
Practice Address - Fax:208-782-1885
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty