Provider Demographics
NPI:1124398094
Name:STEWART, R DIETRICH (LMFA)
Entity Type:Individual
Prefix:MS
First Name:R DIETRICH
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:LMFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790172
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-7901
Mailing Address - Country:US
Mailing Address - Phone:612-290-8825
Mailing Address - Fax:
Practice Address - Street 1:2101-D YAGER CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273
Practice Address - Country:US
Practice Address - Phone:612-290-8825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7060A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist