Healthcare Provider Details

I. General information

NPI: 1518581099
Provider Name (Legal Business Name): THERESA LYNN STEWART LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA LYNN WILKS

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 NEWPORT WAY
ROSEVILLE CA
95661-5315
US

IV. Provider business mailing address

1110 NEWPORT WAY
ROSEVILLE CA
95661-5315
US

V. Phone/Fax

Practice location:
  • Phone: 916-532-3628
  • Fax:
Mailing address:
  • Phone: 916-532-3628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: