Healthcare Provider Details

I. General information

NPI: 1447840889
Provider Name (Legal Business Name): IAN STOUT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

IV. Provider business mailing address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

V. Phone/Fax

Practice location:
  • Phone: 419-747-3322
  • Fax:
Mailing address:
  • Phone: 419-747-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2406283
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180236
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: