Provider Demographics
NPI:1205814266
Name:ENSIGN, SCOTT O (MPT JSCC)
Entity Type:Individual
Prefix:MISS
First Name:SCOTT
Middle Name:O
Last Name:ENSIGN
Suffix:
Gender:M
Credentials:MPT JSCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 CORPORATE CENTER CT SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5901
Mailing Address - Country:US
Mailing Address - Phone:360-412-1368
Mailing Address - Fax:360-412-1391
Practice Address - Street 1:5205 CORPORATE CENTER CT SE
Practice Address - Street 2:SUITE C
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5901
Practice Address - Country:US
Practice Address - Phone:360-412-1367
Practice Address - Fax:360-412-1391
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7102437Medicaid
WA0142413OtherLABOR & INDUST
WAGAB21484Medicare ID - Type Unspecified
WA0142413OtherLABOR & INDUST