Provider Demographics
NPI:1750138145
Name:STEWART, SAMUEL LYLE
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LYLE
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 E ROSEVILLE PKWY APT 718
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-6427
Mailing Address - Country:US
Mailing Address - Phone:916-704-4440
Mailing Address - Fax:
Practice Address - Street 1:10940 FAIR OAKS BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5958
Practice Address - Country:US
Practice Address - Phone:916-426-2757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC12571101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor