Provider Demographics
NPI:1841400553
Name:HARLEY, SCOTT (ATC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:HARLEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 DONNA MARIE DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-6898
Mailing Address - Country:US
Mailing Address - Phone:314-304-2690
Mailing Address - Fax:314-529-9947
Practice Address - Street 1:650 MARYVILLE UNIVERSITY DR
Practice Address - Street 2:DEPARTMENT OF ATHLETICS
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-529-9314
Practice Address - Fax:314-529-9947
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1053392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer