Provider Demographics
NPI:1548381098
Name:STEWART, JR., GEORGE VANCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:VANCE
Last Name:STEWART, JR.
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2316
Mailing Address - Country:US
Mailing Address - Phone:901-438-8755
Mailing Address - Fax:901-685-2570
Practice Address - Street 1:5950 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2316
Practice Address - Country:US
Practice Address - Phone:901-685-2570
Practice Address - Fax:901-685-2570
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1032103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP1032OtherLICENSURE NUMBER