Provider Demographics
NPI:1508403767
Name:SCOTT, RENIA
Entity Type:Individual
Prefix:
First Name:RENIA
Middle Name:
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 1:5211 BERKSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3205
Mailing Address - Country:US
Mailing Address - Phone:313-421-4130
Mailing Address - Fax:
Practice Address - Street 1:5211 BERKSHIRE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224
Practice Address - Country:US
Practice Address - Phone:313-421-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3747A0650X, 172V00000X, 376J00000X
MI4703058673164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No172V00000XOther Service ProvidersCommunity Health Worker
No376J00000XNursing Service Related ProvidersHomemaker