Provider Demographics
NPI:1164204350
Name:STOUT, TRACI LYNN (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:STOUT
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:CORCORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAT, LAT, ATC
Mailing Address - Street 1:1635 CAREGIVER CIR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 CAREGIVER CIR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8529
Practice Address - Country:US
Practice Address - Phone:605-755-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD06952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer