Basic Information
| Provider Information | |||||||||
| NPI: | 1114696655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3394 GATEWAY LAKES DR | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431239373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147781819 | ||||||||
| FaxNumber: | 6148752116 | ||||||||
| Practice Location | |||||||||
| Address1: | 5665 HOOVER RD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431239280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148752371 | ||||||||
| FaxNumber: | 6148752116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.