Provider Demographics
NPI:1255760245
Name:SCOTT, BERTINA
Entity type:Individual
Prefix:
First Name:BERTINA
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 1:403 KNOLLWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-9689
Mailing Address - Country:US
Mailing Address - Phone:704-984-0553
Mailing Address - Fax:
Practice Address - Street 1:43653 COLONIAL HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NC
Practice Address - Zip Code:28127-9580
Practice Address - Country:US
Practice Address - Phone:704-422-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL084107320800000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness