Provider Demographics
NPI:1801227996
Name:CORLISS, SCOTT (NCTMB)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:CORLISS
Suffix:
Gender:M
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MANCHESTER SQ
Mailing Address - Street 2:#120
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-8001
Mailing Address - Country:US
Mailing Address - Phone:603-812-7535
Mailing Address - Fax:603-766-3140
Practice Address - Street 1:14 MANCHESTER SQ STE 120
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-8003
Practice Address - Country:US
Practice Address - Phone:603-812-7535
Practice Address - Fax:603-766-3140
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2991M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist