Healthcare Provider Details

I. General information

NPI: 1053673400
Provider Name (Legal Business Name): MR. SCOTT RAY-SHAYWN HARRISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 ROSIN CT STE 180
SACRAMENTO CA
95834
US

IV. Provider business mailing address

6520 LA CIENEGA DR
NORTH HIGHLANDS CA
95660-4029
US

V. Phone/Fax

Practice location:
  • Phone: 916-283-8259
  • Fax:
Mailing address:
  • Phone: 916-613-5120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: