Provider Demographics
NPI:1740758507
Name:SCOTT, MAZIE GRACE
Entity Type:Individual
Prefix:
First Name:MAZIE
Middle Name:GRACE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:MARYLHURST
Mailing Address - State:OR
Mailing Address - Zip Code:97036-0368
Mailing Address - Country:US
Mailing Address - Phone:503-675-2224
Mailing Address - Fax:
Practice Address - Street 1:2507 CHRISTIE DR.
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-635-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122994Medicaid