Provider Demographics
NPI:1790357010
Name:SCOTT, HEATHER LYNN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:PHILLIPSWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3120 OLD FAITHFUL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5890
Mailing Address - Country:US
Mailing Address - Phone:307-369-1410
Mailing Address - Fax:
Practice Address - Street 1:3120 OLD FAITHFUL RD STE 100
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5890
Practice Address - Country:US
Practice Address - Phone:307-369-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician