Provider Demographics
NPI:1821068925
Name:STROUT, TERESA (PHD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:STROUT
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 1:829 N DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-1795
Mailing Address - Country:US
Mailing Address - Phone:765-452-6700
Mailing Address - Fax:765-452-7470
Practice Address - Street 1:829 N DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-1795
Practice Address - Country:US
Practice Address - Phone:765-452-6700
Practice Address - Fax:765-452-7470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041311A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233120AMedicare ID - Type Unspecified