Provider Demographics
NPI:1962629758
Name:STEWART, TANYA LENAE (LOT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:LENAE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FILLMORE ST APT D
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4345
Mailing Address - Country:US
Mailing Address - Phone:940-224-5083
Mailing Address - Fax:940-691-2193
Practice Address - Street 1:4600 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4935
Practice Address - Country:US
Practice Address - Phone:940-691-1710
Practice Address - Fax:940-691-2193
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109207225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist