Basic Information
Provider Information | |||||||||
NPI: | 1477837938 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | VALERIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PLMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FRAZIER | ||||||||
OtherFirstName: | VALERIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PLMSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 634 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723153336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707806986 | ||||||||
FaxNumber: | 8707806987 | ||||||||
Practice Location | |||||||||
Address1: | 634 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723153336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707806986 | ||||||||
FaxNumber: | 8707806987 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2011 | ||||||||
LastUpdateDate: | 10/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   | AR | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.