Provider Demographics
NPI:1053903005
Name:STEWART, LORENE MICHELLE (LADC)
Entity type:Individual
Prefix:
First Name:LORENE
Middle Name:MICHELLE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 COUNTY ROAD 10 STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3064
Mailing Address - Country:US
Mailing Address - Phone:763-515-9154
Mailing Address - Fax:
Practice Address - Street 1:3300 COUNTY ROAD 10 STE 100
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3064
Practice Address - Country:US
Practice Address - Phone:763-515-9154
Practice Address - Fax:612-444-3292
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305489101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)