Healthcare Provider Details

I. General information

NPI: 1972194520
Provider Name (Legal Business Name): LEROY SCOTT JR. MD,MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 CHOUTEAU AVE FL 4
SAINT LOUIS MO
63110-1754
US

IV. Provider business mailing address

3818 LARAMIE RD
ELLENWOOD GA
30294-6651
US

V. Phone/Fax

Practice location:
  • Phone: 314-696-2090
  • Fax:
Mailing address:
  • Phone: 770-468-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: