Provider Demographics
NPI:1396048187
Name:TROUT, MICHAEL DAVID (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:TROUT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 E CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-7755
Mailing Address - Country:US
Mailing Address - Phone:217-344-3212
Mailing Address - Fax:217-344-1506
Practice Address - Street 1:2808 E CONCORD RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7755
Practice Address - Country:US
Practice Address - Phone:217-344-3212
Practice Address - Fax:217-344-1506
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005539101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor