Provider Demographics
NPI:1093442865
Name:STOUT, DAVID WAYNE JR (RADT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:STOUT
Suffix:JR
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4925
Mailing Address - Country:US
Mailing Address - Phone:559-625-4100
Mailing Address - Fax:559-625-1970
Practice Address - Street 1:120 W SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4925
Practice Address - Country:US
Practice Address - Phone:559-625-4100
Practice Address - Fax:559-625-1970
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1385150420101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)