Healthcare Provider Details

I. General information

NPI: 1073667622
Provider Name (Legal Business Name): PHYLISS D. STOUT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GAULT AVE S
FORT PAYNE AL
35967-1824
US

IV. Provider business mailing address

300 GAULT AVE S
FORT PAYNE AL
35967-1824
US

V. Phone/Fax

Practice location:
  • Phone: 256-997-9356
  • Fax: 256-997-9314
Mailing address:
  • Phone: 256-997-9356
  • Fax: 256-997-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1592C
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1592C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: