Provider Demographics
NPI:1700090453
Name:STEWART, JOHN MICHAEL (BUS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:STEWART
Suffix:
Gender:M
Credentials:BUS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 STAGECOACH CIR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6792
Mailing Address - Country:US
Mailing Address - Phone:505-863-3377
Mailing Address - Fax:505-722-5622
Practice Address - Street 1:100 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6256
Practice Address - Country:US
Practice Address - Phone:505-863-3377
Practice Address - Fax:505-722-5622
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0076911101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)