Basic Information
| Provider Information | |||||||||
| NPI: | 1023566296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | SHANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | SHANDRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3333 DEPOSIT DR NE STE 120 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495461467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3124 N WELLNESS DR STE 50 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494248121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2016 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801110118 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 1041C0700X | 6851110118 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.