Provider Demographics
NPI:1053119297
Name:STOUT, DARA
Entity type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:STOUT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:WAYNETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47990-0162
Mailing Address - Country:US
Mailing Address - Phone:765-326-1501
Mailing Address - Fax:
Practice Address - Street 1:108 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAYNETOWN
Practice Address - State:IN
Practice Address - Zip Code:47990-8022
Practice Address - Country:US
Practice Address - Phone:765-326-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician