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General NPI Number Information
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NPI Number | 1619391091
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Entity Type | Individual
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Provider Name | THEODORA SCOTT MS, ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 02/06/2014
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Last Update Date | 02/12/2021
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Provider Practice Location Address
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Address Line | 640 MARY MCLEOD BETHUNE BLVD
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-3211
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Country | US
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Telephone | 386-481-2282
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Fax |
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Provider Business Mailing Address
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Address Line | 5400 S WILLIAMSON BLVD APT 6-204
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City | PORT ORANGE
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State | FL
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Zip | 32128-6550
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Country | US
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Telephone | 910-934-2930
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL5323
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2211
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License Number State | NC
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