=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962748657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINICK A SCALISE PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2012
-----------------------------------------------------
Last Update Date | 09/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 N MUR LEN RD
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66062-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-360-9221
-----------------------------------------------------
Fax | 913-764-1195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 N MUR LEN RD
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66062-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-360-9221
-----------------------------------------------------
Fax | 913-764-1195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 05224
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 2322
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 2015010530
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------