Provider Demographics
NPI:1275601577
Name:SCOTT, SHANNON E (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11107 WURZBACH RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2500
Mailing Address - Country:US
Mailing Address - Phone:210-697-1866
Mailing Address - Fax:210-697-1867
Practice Address - Street 1:11107 WURZBACH RD
Practice Address - Street 2:SUITE 403
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2500
Practice Address - Country:US
Practice Address - Phone:210-697-1866
Practice Address - Fax:210-697-1867
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23728103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205136900OtherTEXAS WORKER'S COMP
TX23728OtherSTATE LICENSE
TX00D50BOtherBLUE CROSS BLUE SHIELD
TX032647201Medicaid
TX032647201Medicaid