Provider Demographics
NPI:1710564455
Name:MASHBURN, SCOTT
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:MASHBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E MILLSAP RD STE 109
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4862
Mailing Address - Country:US
Mailing Address - Phone:479-935-2300
Mailing Address - Fax:
Practice Address - Street 1:509 E MILLSAP RD STE 109
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4862
Practice Address - Country:US
Practice Address - Phone:479-935-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ARCIT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty