Provider Demographics
NPI:1417740846
Name:RODEFELT, SCOTT KNOWLTON
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:KNOWLTON
Last Name:RODEFELT
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 1:201 SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3943
Mailing Address - Country:US
Mailing Address - Phone:574-253-3266
Mailing Address - Fax:
Practice Address - Street 1:902 E MARKET ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3825
Practice Address - Country:US
Practice Address - Phone:317-918-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9370883991OtherLICENSE
INI632OtherIDENTOGO
INRBT-24-6693-831389OtherBACB