MEDICARE: DR. SCOTT T. SERVISS PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	4608	MA
2	101YM0800X	Mental Health Counselor	001854	CT

General Provider Information

NPI Number	:	1457498164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT T. SERVISS PSY.D.

Provider Business Mailing Address
First Line	:	42 BEN MERRILL RD
Second Line	:
City	:	CLINTON
State	:	CT
Zip	:	06413-1232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 CHICAGO AVE
Second Line	:
City	:	GROTON
State	:	CT
Zip	:	06340-4907
Country	:	US
Telephone Number	:	860-437-2188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	08/09/2013

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