Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 106E00000X | Assistant Behavior Analyst | 1114356797 | CA |
NPI | 1114356797 |
---|---|
Provider Name | Sydney Shanel Stewart |
First Address | Victorville, CA 92395-5144 |
Second Address | Victorville, CA 92395-5144 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/11/2013 |
Last Update Date | 12/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1114356797 | (05) | CA |