Provider Demographics
NPI:1750520367
Name:STEWART, MARK R (EDD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:STEWART
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3750
Mailing Address - Country:US
Mailing Address - Phone:857-523-9344
Mailing Address - Fax:
Practice Address - Street 1:205 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3750
Practice Address - Country:US
Practice Address - Phone:857-523-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMH1076MF106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist