MEDICARE: SHIRLEY SCOTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		GA
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1568981751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLEY SCOTT

Provider Business Mailing Address
First Line	:	858 WYNBROKE PARKWAY
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087
Country	:	US
Telephone Number	:	305-354-6470
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 HAAG DR
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093
Country	:	US
Telephone Number	:	305-354-6470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2017
Last Update Date	:	03/11/2026

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Directions to “ SHIRLEY SCOTT ” Practice Location

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