=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104491125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARRETT OUTLAND MA, CCC-SLP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4641 GULFSTARR DR STE 102
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-964-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4641 GULFSTARR DR STE 102
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-3776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-964-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP-3517
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP3946
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 35099
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2202010958
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146016774
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA20348
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 41YS01202600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP.0005540
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SL017036
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 210009
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 5303
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 120579
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------