Provider Demographics
NPI:1073667622
Name:STOUT, PHYLISS D (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLISS
Middle Name:D
Last Name:STOUT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GAULT AVE S
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-1824
Mailing Address - Country:US
Mailing Address - Phone:256-997-9356
Mailing Address - Fax:256-997-9314
Practice Address - Street 1:300 GAULT AVE S
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-1824
Practice Address - Country:US
Practice Address - Phone:256-997-9356
Practice Address - Fax:256-997-9314
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1592C261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51553422Medicaid
AL51553422STOOtherBCBS OF AL PROVIDER #
AL51553422Medicaid