Provider Demographics
NPI:1972860625
Name:SCOTT, OPAL
Entity Type:Individual
Prefix:MS
First Name:OPAL
Middle Name:
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 1:15 HUCKLEBERRY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1541
Mailing Address - Country:US
Mailing Address - Phone:860-688-2211
Mailing Address - Fax:
Practice Address - Street 1:15 HUCKLEBERRY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-1541
Practice Address - Country:US
Practice Address - Phone:860-688-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT374J00000X374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT374J00000XOtherDOULA -HEALTH CARE PROVIDER TAXONOMY CODE SET - NURSING SERVICE RELATED PROVIDER
CT374J00000XOtherDOULA