1710219910 NPI number — JAY R STEWART PHD, PCC-S, LICDC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710219910 NPI number — JAY R STEWART PHD, PCC-S, LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
JAY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, PCC-S, LICDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710219910
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3425 EXECUTIVE PKWY OH 4360
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-1326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-531-3500
Provider Business Mailing Address Fax Number:
419-531-3500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3425 EXECUTIVE PKWY
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-531-3500
Provider Business Practice Location Address Fax Number:
419-531-3500
Provider Enumeration Date:
02/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E1319 . This is a "OHIO COUNSELOR LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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