Provider Demographics
NPI:1093957243
Name:SCOTCH, TRESA L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:L
Last Name:SCOTCH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3047
Mailing Address - Country:US
Mailing Address - Phone:386-244-9519
Mailing Address - Fax:
Practice Address - Street 1:2765 REBECCA LN STE 2
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8326
Practice Address - Country:US
Practice Address - Phone:386-244-9519
Practice Address - Fax:386-873-4781
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12336235Z00000X
NY014843235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106846Medicare Oscar/Certification