Healthcare Provider Details

I. General information

NPI: 1184059370
Provider Name (Legal Business Name): MARY STOUT M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8720
  • Fax:
Mailing address:
  • Phone: 360-330-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60401283
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: