Provider Demographics
NPI:1689212912
Name:STEWART, MICHAELA RENEE (MED)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:RENEE
Last Name:STEWART
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 SOUTHWEST DR STE 218
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-2292
Mailing Address - Country:US
Mailing Address - Phone:325-692-4048
Mailing Address - Fax:
Practice Address - Street 1:4150 SOUTHWEST DR STE 218
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-2292
Practice Address - Country:US
Practice Address - Phone:325-692-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health