Healthcare Provider Details

I. General information

NPI: 1336237478
Provider Name (Legal Business Name): ANTOINETTE MARIE STOUT MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6419 S HOWELL AVE
OAK CREEK WI
53154-1103
US

IV. Provider business mailing address

3394 W SYCAMORE ST
FRANKLIN WI
53132-8348
US

V. Phone/Fax

Practice location:
  • Phone: 414-304-5713
  • Fax:
Mailing address:
  • Phone: 414-423-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3494-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: