=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316413859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIE SCOTT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2018
-----------------------------------------------------
Last Update Date | 10/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 MAIN ST FL 2
-----------------------------------------------------
City | NIANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06357-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-716-0294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 MAYNARD RD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06420-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-716-0294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 008447
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------