1467838649 NPI number — MADRA STOUT SPEECH-LANGUAGE PATH

Table of content: MADRA STOUT SPEECH-LANGUAGE PATH (NPI 1467838649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467838649 NPI number — MADRA STOUT SPEECH-LANGUAGE PATH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOUT
Provider First Name:
MADRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SPEECH-LANGUAGE PATH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467838649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29587-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9405 HIGHWAY 17 BYP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-9301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-773-0488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  5786 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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