Healthcare Provider Details

I. General information

NPI: 1912411182
Provider Name (Legal Business Name): MR. ROBERT STEWART II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19319 BIRCHRIDGE ST
SOUTHFIELD MI
48075-5837
US

IV. Provider business mailing address

19319 BIRCHRIDGE ST
SOUTHFIELD MI
48075-5837
US

V. Phone/Fax

Practice location:
  • Phone: 313-460-1809
  • Fax: 248-223-9105
Mailing address:
  • Phone: 313-460-1809
  • Fax: 248-223-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: