Provider Demographics
NPI:1356467682
Name:STEWART, CORINNA FODASKI
Entity Type:Individual
Prefix:
First Name:CORINNA
Middle Name:FODASKI
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:VT
Mailing Address - Zip Code:05733-8471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:VT
Practice Address - Zip Code:05733-8471
Practice Address - Country:US
Practice Address - Phone:802-247-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000241101YA0400X
VT047-0000612103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling