Provider Demographics
NPI:1114143146
Name:REISMAN, SCOTT (PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:REISMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 E SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5009
Mailing Address - Country:US
Mailing Address - Phone:954-294-9962
Mailing Address - Fax:
Practice Address - Street 1:1050 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5805
Practice Address - Country:US
Practice Address - Phone:954-294-9962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4332103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73737AMedicare ID - Type Unspecified
FL73737AMedicare UPIN
FL73737BMedicare ID - Type Unspecified
FL73737CMedicare UPIN