Provider Demographics
NPI:1164589669
Name:FIDLER, SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:FIDLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12176 S 1000 E STE 8F
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9734
Mailing Address - Country:US
Mailing Address - Phone:801-619-3569
Mailing Address - Fax:801-576-7540
Practice Address - Street 1:12176 S 1000 E STE 8F
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9734
Practice Address - Country:US
Practice Address - Phone:801-619-3569
Practice Address - Fax:801-576-7540
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5338272-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067999Medicare UPIN