=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861695975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT WILLIAM IRWIN B.A., CAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3969 4TH AVE SUITE 210
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-278-0795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3722 DOVE ST APT. B
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-278-0795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 01-040496 CAS
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------