MEDICARE: DONNA MCDONALD STOUT LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	7614	TX
2	101YP2500X	Professional Counselor	16737	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7614	OTHER	TX	TEXAS LICENSED CHEMICAL DEPENDENCY COUNSELOR
2	16737	OTHER	TX	TEXAS LICENSED PROFESSIONAL COUNSELOR

General Provider Information

NPI Number	:	1598274771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA MCDONALD STOUT LPC

Provider Business Mailing Address
First Line	:	3001A W 5TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2206
Country	:	US
Telephone Number	:	817-338-0311
Fax Number	:	817-332-9075

Provider Business Practice Location Address
First Line	:	3001A W 5TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2206
Country	:	US
Telephone Number	:	817-338-0311
Fax Number	:	817-332-9075

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

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	07/21/2022

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Directions to “ DONNA MCDONALD STOUT LPC” Practice Location

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