Provider Demographics
NPI:1063024206
Name:STEWART, SARDE (MS)
Entity Type:Individual
Prefix:
First Name:SARDE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PINE CT
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2673
Mailing Address - Country:US
Mailing Address - Phone:909-997-8496
Mailing Address - Fax:
Practice Address - Street 1:15490 CIVIC DR STE 208
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2924
Practice Address - Country:US
Practice Address - Phone:442-327-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-20-46528103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty