Provider Demographics
NPI:1154460806
Name:SCROGGINS, KATHY KAY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:KAY
Last Name:SCROGGINS
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 1:112 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5836
Mailing Address - Country:US
Mailing Address - Phone:928-753-5649
Mailing Address - Fax:
Practice Address - Street 1:2299 E BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0736
Practice Address - Country:US
Practice Address - Phone:928-681-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554156OtherAHCCCS PROVIDER