Provider Demographics
NPI:1437409620
Name:STEWART, SHANICE RENEE
Entity Type:Individual
Prefix:MRS
First Name:SHANICE
Middle Name:RENEE
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 1:3369 DURRETT DR
Mailing Address - Street 2:APT. 73
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-8630
Mailing Address - Country:US
Mailing Address - Phone:434-378-6181
Mailing Address - Fax:
Practice Address - Street 1:3369 DURRETT DR
Practice Address - Street 2:APT. 73
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-8630
Practice Address - Country:US
Practice Address - Phone:434-378-6181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness