Provider Demographics
NPI:1427506120
Name:STOUT, BRIAN JONATHAN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JONATHAN
Last Name:STOUT
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7968 RAMBLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7170
Mailing Address - Country:US
Mailing Address - Phone:734-216-5132
Mailing Address - Fax:
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3390
Practice Address - Country:US
Practice Address - Phone:734-216-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010021912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer