Provider Demographics
NPI:1245575216
Name:SCOTT, GWEN (PTA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12325 W CADDY CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6561
Mailing Address - Country:US
Mailing Address - Phone:208-477-7373
Mailing Address - Fax:
Practice Address - Street 1:12325 W CADDY CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6561
Practice Address - Country:US
Practice Address - Phone:208-477-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2114225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant