Provider Demographics
NPI:1821609843
Name:SCOTT, DERRICK DONTAE (LMT)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:DONTAE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 HAMPTON BLVD APT A5
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1661
Mailing Address - Country:US
Mailing Address - Phone:757-675-0533
Mailing Address - Fax:
Practice Address - Street 1:1811 HAMPTON BLVD APT A5
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1661
Practice Address - Country:US
Practice Address - Phone:757-675-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist