Provider Demographics
NPI:1477207504
Name:SCOTT, SANDRA BARNES
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:BARNES
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:ZELLWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32798-0453
Mailing Address - Country:US
Mailing Address - Phone:352-321-0969
Mailing Address - Fax:
Practice Address - Street 1:6578 WILLOW ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-321-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019921700Medicaid