Provider Demographics
NPI:1316205172
Name:STOUT, MARIANNE SEVILLA (PHD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:SEVILLA
Last Name:STOUT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 WOODVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-1905
Mailing Address - Country:US
Mailing Address - Phone:512-574-5854
Mailing Address - Fax:
Practice Address - Street 1:8705 SHOAL CREEK BLVD
Practice Address - Street 2:108
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6802
Practice Address - Country:US
Practice Address - Phone:512-436-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36011103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling