Provider Demographics
NPI:1720370398
Name:STEWART, EDITH VIRGINIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:VIRGINIA
Last Name:STEWART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-208-5120
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 630
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-208-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist