Provider Demographics
NPI:1578693081
Name:STEWART, LISA NELSON (PHD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:NELSON
Last Name:STEWART
Suffix:
Gender:F
Credentials:PHD, LMHC
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 670681
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-0012
Mailing Address - Country:US
Mailing Address - Phone:954-917-9700
Mailing Address - Fax:561-750-4621
Practice Address - Street 1:1330 SE 4TH AVE STE B
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1958
Practice Address - Country:US
Practice Address - Phone:954-917-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4273101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ8002OtherBC BS PROVIDER NUMBER
FLMH4273OtherLICENSE NUMBER