Provider Demographics
NPI:1932671450
Name:SCOTT, MAYA LEA
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:LEA
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 1:86 FLOYD ST # 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2915
Mailing Address - Country:US
Mailing Address - Phone:617-291-2988
Mailing Address - Fax:
Practice Address - Street 1:635 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1605
Practice Address - Country:US
Practice Address - Phone:617-353-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer