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General NPI Number Information
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NPI Number | 1538466784
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Entity Type | Organization
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Legal Business Name | KENNETH L STEWART, PHD, LTD
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Dates
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Enumeration Date | 02/24/2011
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Last Update Date | 02/24/2011
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Provider Practice Location Address
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Address Line | 11812 WAYZATA BLVD SUITE 120
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City | MINNETONKA
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State | MN
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Zip | 55305-2012
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Country | US
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Telephone | 612-868-0366
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Fax |
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Provider Business Mailing Address
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Address Line | 3108 HENNEPIN AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55408-2619
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Country | US
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Telephone | 612-868-0366
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH LYLE STEWART
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Credential | PHD, LP, LMFT
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Telephone | 612-868-0366
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP2948
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License Number State | MN
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