Healthcare Provider Details

I. General information

NPI: 1831805977
Provider Name (Legal Business Name): AUBREY STOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 TRIBBLE GAP RD STE B
CUMMING GA
30040-2475
US

IV. Provider business mailing address

4689 GOLD DUST TRL
SUGAR HILL GA
30518-6248
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-6115
  • Fax:
Mailing address:
  • Phone: 678-333-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC00831
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: