Provider Demographics
NPI:1720067374
Name:EDINGTON, SCOTT W (PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:EDINGTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-1423
Mailing Address - Country:US
Mailing Address - Phone:860-477-1515
Mailing Address - Fax:860-429-2949
Practice Address - Street 1:MAPLE RIDGE CLINICAL SERVICES, 1066 STORRS ROAD
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06268
Practice Address - Country:US
Practice Address - Phone:860-477-1515
Practice Address - Fax:860-429-2949
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001531103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004099710Medicaid
CT004099710Medicaid