=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790831907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA DILLON-STOUT PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 S SHARON AMITY RD SUITE 302
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-2978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-442-0083
-----------------------------------------------------
Fax | 704-442-8103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 REA FOREST DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-3191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-543-6403
-----------------------------------------------------
Fax | 704-442-8103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2315
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------