MEDICARE: MS. GRACE ANN STOUT LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	217	KS
2	101Y00000X	Counselor	2017044749	MO

General Provider Information

NPI Number	:	1104945567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACE ANN STOUT LCPC

Provider Business Mailing Address
First Line	:	2001 CORONA RD STE 205
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-5924
Country	:	US
Telephone Number	:	573-825-4056
Fax Number	:	913-956-6686

Provider Business Practice Location Address
First Line	:	2001 CORONA RD STE 205
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-5924
Country	:	US
Telephone Number	:	573-825-4056
Fax Number	:	913-956-6686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	05/18/2022

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