Healthcare Provider Details

I. General information

NPI: 1184401143
Provider Name (Legal Business Name): LACRESA MARIE STOUT CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W DIVISION ST
HENRYETTA OK
74437-3815
US

IV. Provider business mailing address

1800 W DIVISION ST
HENRYETTA OK
74437-3815
US

V. Phone/Fax

Practice location:
  • Phone: 918-652-6500
  • Fax:
Mailing address:
  • Phone: 918-652-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2729
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: