Provider Demographics
NPI:1306155585
Name:STOUT-FOWLER, REBECCA (PHD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:STOUT-FOWLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:912 S WOOD ST
Mailing Address - Street 2:CHICAGO
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4300
Mailing Address - Country:US
Mailing Address - Phone:312-413-2037
Mailing Address - Fax:
Practice Address - Street 1:912 S WOOD ST
Practice Address - Street 2:CHICAGO
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4300
Practice Address - Country:US
Practice Address - Phone:312-413-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007763103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical