Provider Demographics
NPI:1760625156
Name:STEWART, WENDELL TRAVIS (LPC)
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:TRAVIS
Last Name:STEWART
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:W TRAVIS
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1825 E NORTHERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3972
Mailing Address - Country:US
Mailing Address - Phone:602-997-2880
Mailing Address - Fax:
Practice Address - Street 1:1825 E NORTHERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3972
Practice Address - Country:US
Practice Address - Phone:602-997-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional