Healthcare Provider Details

I. General information

NPI: 1497807994
Provider Name (Legal Business Name): L. SCOTT FAIRCHILD PSY. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 BEDFORD DR SUITE 106
MELBOURNE FL
32940-1993
US

IV. Provider business mailing address

1370 BEDFORD DR SUITE 106
MELBOURNE FL
32940-1993
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-8887
  • Fax: 321-253-8878
Mailing address:
  • Phone: 321-253-8887
  • Fax: 321-253-8878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 6051
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: