Healthcare Provider Details

I. General information

NPI: 1629168257
Provider Name (Legal Business Name): KENNETH STEWART MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 PINEHURST AVE STE J
SOUTHERN PINES NC
28387-7078
US

IV. Provider business mailing address

1540 PURDUE DRIVE SUITE 200
FAYETTEVILLE NC
28303-5510
US

V. Phone/Fax

Practice location:
  • Phone: 910-693-7777
  • Fax: 910-693-1524
Mailing address:
  • Phone: 910-693-7777
  • Fax: 910-693-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC002108
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: