Provider Demographics
NPI:1639215627
Name:STEWART, LISA RENEE (LPC-MHSP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 S WILLOW AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3100
Mailing Address - Country:US
Mailing Address - Phone:931-537-7485
Mailing Address - Fax:
Practice Address - Street 1:251 S WILLOW AVE STE 8
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3100
Practice Address - Country:US
Practice Address - Phone:931-537-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511295Medicaid