Provider Demographics
NPI:1669516266
Name:SCOTT, ROBERT L (LMFT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:MR
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:5600 GOODMAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-893-6556
Mailing Address - Fax:662-893-1102
Practice Address - Street 1:5600 GOODMAN ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-893-6556
Practice Address - Fax:662-893-1102
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD04-038S101YA0400X
MSTO158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4060799OtherBLUE CROSS BLUE SHIELD TN
0007541221OtherAETNA
497541OtherAETNA
215522OtherCOMPSYCHE