Provider Demographics
NPI:1508870676
Name:ANDERSEN, SCOTT KAY (LCPC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:KAY
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 E 4TH N
Mailing Address - Street 2:SUITE 244
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-6002
Mailing Address - Country:US
Mailing Address - Phone:208-356-0088
Mailing Address - Fax:208-524-3738
Practice Address - Street 1:343 E 4TH N
Practice Address - Street 2:SUITE 244
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6002
Practice Address - Country:US
Practice Address - Phone:208-356-0088
Practice Address - Fax:208-524-3738
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC2823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1164723334Medicaid
ID710C6005OtherRBH
IDD214391OtherVALUE OPTIONS
IDQ7348OtherBLUE CROSS
IDQ7699OtherBLUE CROSS