Healthcare Provider Details

I. General information

NPI: 1164288916
Provider Name (Legal Business Name): SCOTT C STAUTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAY O VAC DR STE 103
MADISON WI
53711-2468
US

IV. Provider business mailing address

2145 FOX AVE
MADISON WI
53711-1920
US

V. Phone/Fax

Practice location:
  • Phone: 608-444-4856
  • Fax:
Mailing address:
  • Phone: 608-444-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5587-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: