=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972170900
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT DAVID HETMAN LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2021
-----------------------------------------------------
Last Update Date | 12/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 EASTERN BLVD BASE SUPPORT BLDG ROOM 201
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-918-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2701 EASTERN BLVD BASE SUPPORT BLDG ROOM 201
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-918-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 0903003166
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904014910
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 32416
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------