Provider Demographics
NPI:1659027894
Name:STEWART, SHAUN (LMT)
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2936 WINDSOR MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4113
Mailing Address - Country:US
Mailing Address - Phone:347-339-9602
Mailing Address - Fax:
Practice Address - Street 1:4625 PIEDMONT ROW DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4285
Practice Address - Country:US
Practice Address - Phone:704-552-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032707225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1725667OtherAMTA