Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 6022766-2501 | UT |
Y | 103T00000X | Psychologist | 6022766-2501 | UT |
NPI | 1013395128 |
---|---|
Provider Name | Kelly Stout |
First Address | Salt Lake City, UT 84102-1971 |
Second Address | Salt Lake City, UT 84108-1287 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2015 |
Last Update Date | 23/11/2021 |