Provider Demographics
NPI:1023502432
Name:STEWART, KIMBERLY DIANE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
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 1:1820 MEMORIAL DR STE 203
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4693
Mailing Address - Country:US
Mailing Address - Phone:931-249-9777
Mailing Address - Fax:931-443-0125
Practice Address - Street 1:1820 MEMORIAL DR STE 203
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4693
Practice Address - Country:US
Practice Address - Phone:931-249-9777
Practice Address - Fax:931-443-0125
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN76341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker