Provider Demographics
NPI:1356719694
Name:SCOTT, ANTONIO TERRILL
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:TERRILL
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 WALLS LN
Mailing Address - Street 2:
Mailing Address - City:CHADBOURN
Mailing Address - State:NC
Mailing Address - Zip Code:28431-8517
Mailing Address - Country:US
Mailing Address - Phone:910-207-2422
Mailing Address - Fax:
Practice Address - Street 1:216 WALLS LANE
Practice Address - Street 2:
Practice Address - City:CHADBOURN
Practice Address - State:NC
Practice Address - Zip Code:28431
Practice Address - Country:US
Practice Address - Phone:910-207-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$Medicaid