Provider Demographics
NPI:1508263674
Name:STOUT, VICKI LEANN (PT)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LEANN
Last Name:STOUT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E COURT AVE
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2304
Mailing Address - Country:US
Mailing Address - Phone:731-645-7932
Mailing Address - Fax:731-645-5195
Practice Address - Street 1:270 E COURT AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2304
Practice Address - Country:US
Practice Address - Phone:731-645-7932
Practice Address - Fax:731-645-5195
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist