Provider Demographics
NPI:1063863702
Name:SCOTT, SHANNAH CLOE
Entity Type:Individual
Prefix:MRS
First Name:SHANNAH
Middle Name:CLOE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 CHIPPENDALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3816
Mailing Address - Country:US
Mailing Address - Phone:970-231-9829
Mailing Address - Fax:
Practice Address - Street 1:4816 CHIPPENDALE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-3816
Practice Address - Country:US
Practice Address - Phone:970-231-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98335375251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO147225OtherTRADING PARTNER ID
CO98335375Medicaid