Provider Demographics
NPI:1639624679
Name:STEWART, RICHARD (ATC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-0686
Mailing Address - Country:US
Mailing Address - Phone:571-264-5214
Mailing Address - Fax:
Practice Address - Street 1:3401 PANTHER PRIDE DR
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-2184
Practice Address - Country:US
Practice Address - Phone:571-238-0944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer