Provider Demographics
NPI:1942935648
Name:STOUT, SHAD LEVI
Entity Type:Individual
Prefix:
First Name:SHAD
Middle Name:LEVI
Last Name:STOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 VERANDA CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-2609
Mailing Address - Country:US
Mailing Address - Phone:985-705-7478
Mailing Address - Fax:
Practice Address - Street 1:1401 DEZARAE APT 3
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5986
Practice Address - Country:US
Practice Address - Phone:210-529-8410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108250104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker