Healthcare Provider Details

I. General information

NPI: 1164204350
Provider Name (Legal Business Name): TRACI LYNN STOUT MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI LYNN CORCORAN MAT, LAT, ATC

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 CAREGIVER CIR
RAPID CITY SD
57702-8529
US

IV. Provider business mailing address

1635 CAREGIVER CIR
RAPID CITY SD
57702-8529
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0695
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: