Provider Demographics
NPI:1740758507
Name:SCOTT, MAZIE GRACE
Entity type:Individual
Prefix:
First Name:MAZIE
Middle Name:GRACE
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 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:2275 S EAGLE RD STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2620
Practice Address - Country:US
Practice Address - Phone:208-514-2520
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8561270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122994Medicaid