Provider Demographics
NPI:1841314812
Name:STEWART, GRETCHEN MICHELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:MICHELLE
Last Name:STEWART
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 AVONDALE CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4272
Mailing Address - Country:US
Mailing Address - Phone:318-549-2815
Mailing Address - Fax:
Practice Address - Street 1:305 AVONDALE CIR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4272
Practice Address - Country:US
Practice Address - Phone:318-549-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4775235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478229Medicaid