Provider Demographics
NPI:1265001820
Name:SHOTT, CONNOR BRYANT
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:BRYANT
Last Name:SHOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 N KYLE LOOP
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1837
Mailing Address - Country:US
Mailing Address - Phone:520-686-1811
Mailing Address - Fax:
Practice Address - Street 1:2187 N VICKEY ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6121
Practice Address - Country:US
Practice Address - Phone:928-527-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician