Provider Demographics
NPI:1942908439
Name:BRAITHWAITE, SCOTT R (PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRIGHAM YOUNG UNIVERSITY
Mailing Address - Street 2:286 TLRB
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:85602
Mailing Address - Country:US
Mailing Address - Phone:801-422-8583
Mailing Address - Fax:
Practice Address - Street 1:BRIGHAM YOUNG UNIVERSITY
Practice Address - Street 2:286 TLRB
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:85602
Practice Address - Country:US
Practice Address - Phone:801-422-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8035128-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical