Provider Demographics
NPI:1902684897
Name:STOUT, VICKA MALONE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:VICKA
Middle Name:MALONE
Last Name:STOUT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2912
Mailing Address - Country:US
Mailing Address - Phone:760-920-2072
Mailing Address - Fax:
Practice Address - Street 1:2918 INDIAN CREEK DR
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2912
Practice Address - Country:US
Practice Address - Phone:760-920-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12976106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist