Provider Demographics
NPI:1942053616
Name:STOUT, AMANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5948
Mailing Address - Country:US
Mailing Address - Phone:217-853-4785
Mailing Address - Fax:
Practice Address - Street 1:363 S MAIN ST STE 240
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1492
Practice Address - Country:US
Practice Address - Phone:217-422-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490270041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical