Provider Demographics
NPI:1790148815
Name:MACINNIS, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MACINNIS
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 1:46540 BARTLETT DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1517
Mailing Address - Country:US
Mailing Address - Phone:313-477-9403
Mailing Address - Fax:
Practice Address - Street 1:905 S CENTER ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3230
Practice Address - Country:US
Practice Address - Phone:313-477-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2021-09-14
Deactivation Date:2018-10-07
Deactivation Code:
Reactivation Date:2018-10-24
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI6361007539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other