Healthcare Provider Details

I. General information

NPI: 1912114703
Provider Name (Legal Business Name): BONNIE JEAN STEWART CDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20552 BLUESTEM PKWY
LYNWOOD IL
60411-8549
US

IV. Provider business mailing address

20552 BLUESTEM PKWY
LYNWOOD IL
60411-8549
US

V. Phone/Fax

Practice location:
  • Phone: 708-507-5511
  • Fax: 708-757-7145
Mailing address:
  • Phone: 708-507-5511
  • Fax: 708-757-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: