Healthcare Provider Details

I. General information

NPI: 1962210054
Provider Name (Legal Business Name): NICOLE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE GALAS

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7274 DIXIE HWY
BRIDGEPORT MI
48722-9702
US

IV. Provider business mailing address

4407 SPURWOOD DR
SAGINAW MI
48603-1176
US

V. Phone/Fax

Practice location:
  • Phone: 313-403-8116
  • Fax:
Mailing address:
  • Phone: 586-295-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: