Provider Demographics
NPI:1023566296
Name:STEWART, SHANDRA (LLMSW)
Entity Type:Individual
Prefix:
First Name:SHANDRA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:SHANDRA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3333 DEPOSIT DR NE STE 120
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-1467
Mailing Address - Country:US
Mailing Address - Phone:616-805-3660
Mailing Address - Fax:
Practice Address - Street 1:3124 N WELLNESS DR STE 50
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8121
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011101181041C0700X
247200000X
MI68511101181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other