Provider Demographics
NPI:1669010609
Name:STEWART, SUSAN DYER
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DYER
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 1:35 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LISBON FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04252-1506
Mailing Address - Country:US
Mailing Address - Phone:207-217-0103
Mailing Address - Fax:
Practice Address - Street 1:37 PARK ST STE 302
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7195
Practice Address - Country:US
Practice Address - Phone:207-330-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5855101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)