Provider Demographics
NPI:1154813590
Name:STOUTT, LEAH ANN TYLER
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ANN TYLER
Last Name:STOUTT
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 1:113 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3519
Mailing Address - Country:US
Mailing Address - Phone:503-263-8903
Mailing Address - Fax:
Practice Address - Street 1:610 HIGH ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2241
Practice Address - Country:US
Practice Address - Phone:503-657-8903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WA61079694235Z00000X
OR17395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician