Provider Demographics
NPI:1295962009
Name:STEWART, LISA V (OTR)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:V
Last Name:STEWART
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 MICHAELS LN
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-3226
Mailing Address - Country:US
Mailing Address - Phone:315-865-6062
Mailing Address - Fax:
Practice Address - Street 1:9217 MICHAELS LN
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13403-3226
Practice Address - Country:US
Practice Address - Phone:315-865-6062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002969-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency