Provider Demographics
NPI:1942295969
Name:STOUT, MARY THERESA (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESA
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 1:4 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-5210
Mailing Address - Country:US
Mailing Address - Phone:570-644-2353
Mailing Address - Fax:570-644-2392
Practice Address - Street 1:4 N 6TH ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-5210
Practice Address - Country:US
Practice Address - Phone:570-644-2353
Practice Address - Fax:570-644-2392
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT001749E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
412246Medicare ID - Type Unspecified