Provider Demographics
NPI:1497083521
Name:STEWART, DEIDRA SHANTE (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:SHANTE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LCSW, LISW
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 1543
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-1543
Mailing Address - Country:US
Mailing Address - Phone:864-681-3798
Mailing Address - Fax:
Practice Address - Street 1:112B BOLT DR
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-1900
Practice Address - Country:US
Practice Address - Phone:864-681-3798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSW.9621 CP1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1041Medicaid