Provider Demographics
NPI:1407037245
Name:SCOTT, KELLY (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 GLATT CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9675
Mailing Address - Country:US
Mailing Address - Phone:503-981-4591
Mailing Address - Fax:503-982-3308
Practice Address - Street 1:559 GLATT CIR STE 1
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9675
Practice Address - Country:US
Practice Address - Phone:503-981-4591
Practice Address - Fax:503-982-3308
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13672171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor