Provider Demographics
NPI:1699206607
Name:SCOTT, LAINE CELEDON
Entity Type:Individual
Prefix:
First Name:LAINE
Middle Name:CELEDON
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:CELEDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2928 SE HAWTHORNE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:540-850-3848
Mailing Address - Fax:
Practice Address - Street 1:2928 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:540-850-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E-10182142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist