MEDICARE: MR. CEDRIC HARLAN SCOTT LIMITED LICENSE PSYC

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	200727	MI
2	103TC2200X	Clinical Child & Adolescent Psychologist
3	103T00000X	Psychologist	6301012964	MI

General Provider Information

NPI Number	:	1871605915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CEDRIC HARLAN SCOTT LIMITED LICENSE PSYC

Provider Business Mailing Address
First Line	:	2416 PECK ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-1431
Country	:	US
Telephone Number	:	231-733-6607
Fax Number	:	231-737-0534

Provider Business Practice Location Address
First Line	:	2416 PECK ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-1431
Country	:	US
Telephone Number	:	231-733-6607
Fax Number	:	231-737-0534

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/11/2025

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