Provider Demographics
NPI:1083381198
Name:STEWART, ATHENA CANDACE (ACLC)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:CANDACE
Last Name:STEWART
Suffix:
Gender:F
Credentials:ACLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12584 PRYOR RD
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101
Mailing Address - Country:US
Mailing Address - Phone:406-200-2612
Mailing Address - Fax:
Practice Address - Street 1:1230 NORTH 30TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101
Practice Address - Country:US
Practice Address - Phone:406-534-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-48296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)