Provider Demographics
NPI:1497211825
Name:SCOTT, BENJAMIN TYLER (LCSW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TYLER
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 AGUA FRIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2448
Mailing Address - Country:US
Mailing Address - Phone:231-769-2010
Mailing Address - Fax:
Practice Address - Street 1:941 AGUA FRIA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2448
Practice Address - Country:US
Practice Address - Phone:231-769-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-03511041C0700X
KY2538371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical