MEDICARE: MS. CAROLINE RIDOUT STEWART LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS14173	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1021795	OTHER		CIGNA
2	11655002	OTHER		CAQH

General Provider Information

NPI Number	:	1477743573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLINE RIDOUT STEWART LCSW

Provider Business Mailing Address
First Line	:	1527 W LEWIS ST
Second Line	:	STE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1220
Country	:	US
Telephone Number	:	619-491-0080
Fax Number	:	619-296-1863

Provider Business Practice Location Address
First Line	:	1527 W LEWIS ST
Second Line	:	STE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1220
Country	:	US
Telephone Number	:	619-491-0080
Fax Number	:	619-296-1863

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	07/26/2007

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