Provider Demographics
NPI:1225199052
Name:STEWART, NATHANIEL JR (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:STEWART
Suffix:JR
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6739
Mailing Address - Country:US
Mailing Address - Phone:651-645-0645
Mailing Address - Fax:651-645-0630
Practice Address - Street 1:1535 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6739
Practice Address - Country:US
Practice Address - Phone:651-645-0645
Practice Address - Fax:651-645-0630
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2279103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-73761OtherMEDICA
MN86656STOtherBCBS
MNUCARE MNOther111770
MNMN HEALTHCARE PROGRAMedicare UPIN