Healthcare Provider Details

I. General information

NPI: 1083196612
Provider Name (Legal Business Name): MS. KATIE ROSE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 MILL ST STE M1
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

PO BOX 5
COTTAGE GROVE OR
97424-0001
US

V. Phone/Fax

Practice location:
  • Phone: 541-767-4167
  • Fax: 541-746-9982
Mailing address:
  • Phone: 541-942-3939
  • Fax: 541-942-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: