Healthcare Provider Details

I. General information

NPI: 1659735496
Provider Name (Legal Business Name): DANIELLE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 ROUTE 112 BUILDING 9 SUITE 2
MEDFORD NY
11763-1446
US

IV. Provider business mailing address

3251 ROUTE 112 BUILDING 9 SUITE 2
MEDFORD NY
11763-1446
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number095089
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: