Provider Demographics
NPI:1538778865
Name:STUART, MICHAEL BLAKE (RADT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BLAKE
Last Name:STUART
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 SAVONA WAY
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-4841
Mailing Address - Country:US
Mailing Address - Phone:818-661-9729
Mailing Address - Fax:
Practice Address - Street 1:510 SAVONA WAY
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-4841
Practice Address - Country:US
Practice Address - Phone:818-661-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1369011019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)