Provider Demographics
NPI:1053673400
Name:HARRISON, SCOTT RAY-SHAYWN
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:RAY-SHAYWN
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 LA CIENEGA DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-4029
Mailing Address - Country:US
Mailing Address - Phone:916-613-5120
Mailing Address - Fax:
Practice Address - Street 1:3810 ROSIN CT STE 180
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834
Practice Address - Country:US
Practice Address - Phone:916-283-8259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
390200000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program