Healthcare Provider Details

I. General information

NPI: 1205410016
Provider Name (Legal Business Name): KYLIE DEANNA STOUGH LPC/MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W TYRONE RD
OAK RIDGE TN
37830-6517
US

IV. Provider business mailing address

12501 CHOTO MILL LN
KNOXVILLE TN
37922-0615
US

V. Phone/Fax

Practice location:
  • Phone: 865-481-6175
  • Fax:
Mailing address:
  • Phone: 865-392-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number228872
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4660
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: