Provider Demographics
NPI:1235724451
Name:STOUT, TAMYKA (LMT)
Entity Type:Individual
Prefix:
First Name:TAMYKA
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 JASEN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2430
Mailing Address - Country:US
Mailing Address - Phone:646-946-5912
Mailing Address - Fax:
Practice Address - Street 1:1769 JASEN AVE APT 2
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2430
Practice Address - Country:US
Practice Address - Phone:646-946-5912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018749-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty