Basic Information
| Provider Information | |||||||||
| NPI: | 1225101645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUTLAW | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986614918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606966525 | ||||||||
| FaxNumber: | 7027378255 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986614918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606966525 | ||||||||
| FaxNumber: | 3604180418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 60099189 | WA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 100508237 | 05 | NV | MEDICAID |