Provider Demographics
NPI:1235482233
Name:SCOTT, MELVERN JR (LSW)
Entity Type:Individual
Prefix:MR
First Name:MELVERN
Middle Name:
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 121
Mailing Address - Street 2:109 RAYNER RD
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762
Mailing Address - Country:US
Mailing Address - Phone:662-545-1515
Mailing Address - Fax:
Practice Address - Street 1:109 RAYNER RD
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762
Practice Address - Country:US
Practice Address - Phone:662-545-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSW7939104100000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No374U00000XNursing Service Related ProvidersHome Health Aide