Provider Demographics
NPI:1659878130
Name:STEWART, STUART BRYAN (PEER SUPPORT SPECIAL)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:BRYAN
Last Name:STEWART
Suffix:
Gender:M
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S I ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1616
Mailing Address - Country:US
Mailing Address - Phone:541-417-0987
Mailing Address - Fax:
Practice Address - Street 1:215 N G ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1417
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:541-947-6020
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241295Medicaid