Provider Demographics
NPI:1114388519
Name:STOUT, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 US HIGHWAY 42 N
Mailing Address - Street 2:
Mailing Address - City:ASHLEY
Mailing Address - State:OH
Mailing Address - Zip Code:43003-9702
Mailing Address - Country:US
Mailing Address - Phone:740-369-4482
Mailing Address - Fax:740-369-4908
Practice Address - Street 1:9001 US HIGHWAY 42 N
Practice Address - Street 2:
Practice Address - City:ASHLEY
Practice Address - State:OH
Practice Address - Zip Code:43003-9702
Practice Address - Country:US
Practice Address - Phone:740-369-4482
Practice Address - Fax:740-369-4908
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW 1100049104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker