Healthcare Provider Details

I. General information

NPI: 1558122937
Provider Name (Legal Business Name): SCOTT GROUP 010 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 N 43RD AVE STE 10
GLENDALE AZ
85302-3849
US

IV. Provider business mailing address

9250 N 43RD AVE STE 10
GLENDALE AZ
85302-3849
US

V. Phone/Fax

Practice location:
  • Phone: 480-433-5593
  • Fax:
Mailing address:
  • Phone: 480-433-5593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: GARY A SCOTT SR.
Title or Position: CEO
Credential:
Phone: 480-433-5593