Provider Demographics
NPI:1275299596
Name:STOUT, KELSEY CARRASQUILLO (LPC, MA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:CARRASQUILLO
Last Name:STOUT
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7409 ROSE WATER LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-5518
Mailing Address - Country:US
Mailing Address - Phone:678-677-9243
Mailing Address - Fax:
Practice Address - Street 1:9051 EXECUTIVE PARK DR STE 103
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4651
Practice Address - Country:US
Practice Address - Phone:678-404-6779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014919101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty