Provider Demographics
NPI:1033624085
Name:STEWART, BRENT SALISBURY (CCAPP)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:SALISBURY
Last Name:STEWART
Suffix:
Gender:M
Credentials:CCAPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N PARKER ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1323
Mailing Address - Country:US
Mailing Address - Phone:714-639-5546
Mailing Address - Fax:
Practice Address - Street 1:525 N PARKER ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1323
Practice Address - Country:US
Practice Address - Phone:714-639-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA964079133OtherOTHER