Provider Demographics
NPI:1619391091
Name:SCOTT, THEODORA (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:THEODORA
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:5400 S WILLIAMSON BLVD APT 6-204
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6550
Mailing Address - Country:US
Mailing Address - Phone:910-934-2930
Mailing Address - Fax:
Practice Address - Street 1:640 MARY MCLEOD BETHUNE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3211
Practice Address - Country:US
Practice Address - Phone:386-481-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL53232255A2300X
NC22112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer