Provider Demographics
NPI:1720764624
Name:STEWART, CANDACE SHAE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:SHAE
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:KY
Mailing Address - Zip Code:42325
Mailing Address - Country:US
Mailing Address - Phone:270-225-8344
Mailing Address - Fax:
Practice Address - Street 1:4501 MAIN ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:KY
Practice Address - Zip Code:42325
Practice Address - Country:US
Practice Address - Phone:270-225-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant