Provider Demographics
NPI:1689891699
Name:STOUTT, CAROLYN JANE (MSW-ACSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:JANE
Last Name:STOUTT
Suffix:
Gender:F
Credentials:MSW-ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6069 N OAKBANK DR
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4141
Mailing Address - Country:US
Mailing Address - Phone:626-963-9578
Mailing Address - Fax:
Practice Address - Street 1:14600 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3363
Practice Address - Country:US
Practice Address - Phone:626-337-8811
Practice Address - Fax:626-856-5653
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW198281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007302Medicaid
CACBSC210OtherLA-DMH-PROVIDER