Healthcare Provider Details

I. General information

NPI: 1164998936
Provider Name (Legal Business Name): SCOTT ALAN MACKEY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18614 JACKSON STREET
HERMITAGE MO
65668-0125
US

IV. Provider business mailing address

PO BOX 125
HERMITAGE MO
65668-0125
US

V. Phone/Fax

Practice location:
  • Phone: 417-745-2121
  • Fax: 417-745-0056
Mailing address:
  • Phone: 417-745-2121
  • Fax: 417-745-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2018036325
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: