Healthcare Provider Details

I. General information

NPI: 1871605915
Provider Name (Legal Business Name): CEDRIC HARLAN SCOTT LIMITED LICENSE PSYC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 PECK ST
MUSKEGON MI
49444-1431
US

IV. Provider business mailing address

2416 PECK ST
MUSKEGON MI
49444-1431
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-6607
  • Fax: 231-737-0534
Mailing address:
  • Phone: 231-733-6607
  • Fax: 231-737-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number200727
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: