Provider Demographics
NPI:1538466784
Name:KENNETH L STEWART, PHD, LTD
Entity Type:Organization
Organization Name:KENNETH L STEWART, PHD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP, LMFT
Authorized Official - Phone:612-868-0366
Mailing Address - Street 1:3108 HENNEPIN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2619
Mailing Address - Country:US
Mailing Address - Phone:612-868-0366
Mailing Address - Fax:
Practice Address - Street 1:11812 WAYZATA BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2012
Practice Address - Country:US
Practice Address - Phone:612-868-0366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2948103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN945315600Medicaid