=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528201282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL A. SCOTT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2009
-----------------------------------------------------
Last Update Date | 12/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1996 CLIFF VALLEY WAY NE SUITE 106
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-633-2334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2921 PIEDMONT RD NE SUITE C
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-2785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-633-2334
-----------------------------------------------------
Fax | 404-760-1136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC 1620
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT 829
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------