Provider Demographics
NPI:1518581099
Name:STEWART, THERESA LYNN (LPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:STEWART
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:LYNN
Other - Last Name:WILKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 NEWPORT WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5315
Mailing Address - Country:US
Mailing Address - Phone:916-532-3628
Mailing Address - Fax:
Practice Address - Street 1:1110 NEWPORT WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-5315
Practice Address - Country:US
Practice Address - Phone:916-532-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41428167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician