Provider Demographics
NPI:1053348177
Name:STEWART, KYMRA FOWLER (LCSW)
Entity type:Individual
Prefix:
First Name:KYMRA
Middle Name:FOWLER
Last Name:STEWART
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 EXECUTIVE PARK BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8184
Mailing Address - Country:US
Mailing Address - Phone:910-854-0371
Mailing Address - Fax:910-854-0371
Practice Address - Street 1:3960 EXECUTIVE PARK BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461
Practice Address - Country:US
Practice Address - Phone:910-854-0371
Practice Address - Fax:910-854-0371
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0014841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002012Medicaid
NC79895OtherBCBS
NC79895OtherBCBS NC
NC6002012OtherMEDICAID