Basic Information
| Provider Information | |||||||||
| NPI: | 1154958684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | CHARELLE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 CRAIN HWY | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016096900 | ||||||||
| FaxNumber: | 3019341234 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 CRAIN HWY | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016096900 | ||||||||
| FaxNumber: | 3019341234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ADT1919 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.