Healthcare Provider Details

I. General information

NPI: 1467761528
Provider Name (Legal Business Name): WANDA STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8510 SOUTH TEN MILE ROAD
MARYSVALE UT
84750
US

IV. Provider business mailing address

PO BOX 133
MARYSVALE UT
84750-0133
US

V. Phone/Fax

Practice location:
  • Phone: 435-201-9215
  • Fax: 435-527-8883
Mailing address:
  • Phone: 435-201-9215
  • Fax: 435-527-8883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61234363
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: