Healthcare Provider Details

I. General information

NPI: 1689891699
Provider Name (Legal Business Name): CAROLYN JANE STOUTT MSW-ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 RAMONA BLVD
BALDWIN PARK CA
91706-3363
US

IV. Provider business mailing address

6069 N OAKBANK DR
AZUSA CA
91702-4141
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-8811
  • Fax: 626-856-5653
Mailing address:
  • Phone: 626-963-9578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW19828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: