Provider Demographics
NPI:1053639583
Name:SCOTT, KIM (EDD)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15643 DOBBS PEAK LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4560
Mailing Address - Country:US
Mailing Address - Phone:951-536-7845
Mailing Address - Fax:
Practice Address - Street 1:15643 DOBBS PEAK LN
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4560
Practice Address - Country:US
Practice Address - Phone:951-536-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1538-061511P101YA0400X
CA070104802101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool