Provider Demographics
NPI:1912366253
Name:STEWART, KENDALL LAURENCE (MS, ATC, CES, PES)
Entity Type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:LAURENCE
Last Name:STEWART
Suffix:
Gender:M
Credentials:MS, ATC, CES, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 RIDGE AVE
Mailing Address - Street 2:APARTMENT 302
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6725 RIDGE AVE
Practice Address - Street 2:APARTMENT 302
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2452
Practice Address - Country:US
Practice Address - Phone:760-703-4852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0063702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer