Healthcare Provider Details

I. General information

NPI: 1770410565
Provider Name (Legal Business Name): ANYA NICOLE SCOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5552 WILD RIDGE LN
WEST BLOOMFIELD MI
48322-4001
US

IV. Provider business mailing address

5552 WILD RIDGE LN
WEST BLOOMFIELD MI
48322-4001
US

V. Phone/Fax

Practice location:
  • Phone: 248-722-2376
  • Fax:
Mailing address:
  • Phone: 248-722-2376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberS900000120503
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: