Provider Demographics
NPI:1801019146
Name:STOUT, BETHANY S (LADC)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:S
Last Name:STOUT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 OKLAHOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-2711
Mailing Address - Country:US
Mailing Address - Phone:580-327-1825
Mailing Address - Fax:
Practice Address - Street 1:1095 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1252
Practice Address - Country:US
Practice Address - Phone:580-824-0674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK764101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)