MEDICARE: KENNETH STEWART PHD, LP

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	103T00000X	Psychologist	2948	MN

General Provider Information

NPI Number	:	1528165446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH STEWART PHD, LP

Provider Business Mailing Address
First Line	:	3108 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2619
Country	:	US
Telephone Number	:	612-825-4407
Fax Number	:	612-825-0768

Provider Business Practice Location Address
First Line	:	3108 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2619
Country	:	US
Telephone Number	:	612-825-4407
Fax Number	:	612-825-0768

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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