Provider Demographics
NPI:1902136252
Name:STEWART, SHANETTE
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 CENTER RUN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1945
Mailing Address - Country:US
Mailing Address - Phone:317-570-9205
Mailing Address - Fax:317-570-9206
Practice Address - Street 1:8117 CENTER RUN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1945
Practice Address - Country:US
Practice Address - Phone:317-570-9205
Practice Address - Fax:317-570-9206
Is Sole Proprietor?:No
Enumeration Date:2010-01-09
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99040677A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant