Provider Demographics
NPI:1942618608
Name:STEWART, LAURA (ATC, OTC, CSCS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:ATC, OTC, CSCS
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:367 E ALLEN ST APT 25
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-7656
Mailing Address - Country:US
Mailing Address - Phone:608-669-5306
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.0001269261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center