Healthcare Provider Details

I. General information

NPI: 1124282769
Provider Name (Legal Business Name): LARRY A STOUT MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W MAIN ST
MARION IL
62959-1171
US

IV. Provider business mailing address

11531 SUNDERLAND RD
MARION IL
62959-8274
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 618-997-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149004386
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: