Provider Demographics
NPI:1790078871
Name:SCOTT, ELLISA (PHD, LMHC)
Entity type:Individual
Prefix:
First Name:ELLISA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-4305
Mailing Address - Country:US
Mailing Address - Phone:863-261-8900
Mailing Address - Fax:
Practice Address - Street 1:203 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-4305
Practice Address - Country:US
Practice Address - Phone:863-261-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003835200Medicaid