Provider Demographics
NPI:1265735609
Name:STEWART, KYLE RAY (LMP)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RAY
Last Name:STEWART
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 W 12TH AVE APT 335
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-7208
Mailing Address - Country:US
Mailing Address - Phone:509-981-3097
Mailing Address - Fax:
Practice Address - Street 1:10620 W12TH #335
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224
Practice Address - Country:US
Practice Address - Phone:509-981-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMZ 60183711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist