Healthcare Provider Details

I. General information

NPI: 1801510920
Provider Name (Legal Business Name): MR. SCOTT WAYNE MEDEIROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RIVER ST
WELLESLEY MA
02481-2017
US

IV. Provider business mailing address

14 KANSAS AVE
SOMERSET MA
02726-3607
US

V. Phone/Fax

Practice location:
  • Phone: 781-431-1177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10005347
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: