Provider Demographics
NPI:1902324379
Name:STEWART, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-299-1299
Mailing Address - Fax:
Practice Address - Street 1:6929 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-4541
Practice Address - Country:US
Practice Address - Phone:937-259-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)