Provider Demographics
NPI:1336237478
Name:STOUT, ANTOINETTE MARIE (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:STOUT
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3394 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8348
Mailing Address - Country:US
Mailing Address - Phone:414-423-5409
Mailing Address - Fax:
Practice Address - Street 1:6419 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1103
Practice Address - Country:US
Practice Address - Phone:414-304-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3494-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40911800Medicaid