Provider Demographics
NPI:1619483351
Name:STEWART, THERESA DENISE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:DENISE
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8591 LAGOON DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6787
Mailing Address - Country:US
Mailing Address - Phone:734-829-7345
Mailing Address - Fax:
Practice Address - Street 1:300 N HURON ST STE 10
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2842
Practice Address - Country:US
Practice Address - Phone:734-480-0125
Practice Address - Fax:734-480-0125
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703087489164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629279732Medicaid