Provider Demographics
NPI:1225579493
Name:EDWARDS, SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 VANESSA LN
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4359
Mailing Address - Country:US
Mailing Address - Phone:831-295-6330
Mailing Address - Fax:
Practice Address - Street 1:1529 SEABRIGHT AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2528
Practice Address - Country:US
Practice Address - Phone:831-458-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12105405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional