Provider Demographics
NPI:1518391176
Name:DIVINAGRACIA, SCOTT LANO (PTA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:LANO
Last Name:DIVINAGRACIA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:SCOTT
Other - Middle Name:LANO
Other - Last Name:DIVINAGRACIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:5517 ALDERBROOK CT APT 104
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20851-2416
Mailing Address - Country:US
Mailing Address - Phone:417-540-4602
Mailing Address - Fax:
Practice Address - Street 1:5215 W CEDAR LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1548
Practice Address - Country:US
Practice Address - Phone:301-897-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility