Provider Demographics
NPI:1033349162
Name:STEWART, TONJA M (LPC)
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:M
Last Name:STEWART
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 GRANDIN RD SW
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2345
Mailing Address - Country:US
Mailing Address - Phone:540-206-2330
Mailing Address - Fax:540-206-2330
Practice Address - Street 1:1402 GRANDIN RD SW
Practice Address - Street 2:SUITE 209
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2345
Practice Address - Country:US
Practice Address - Phone:540-206-2330
Practice Address - Fax:540-206-2330
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1033349162Medicaid