Provider Demographics
NPI:1811353717
Name:BANGHART, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BANGHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 W MICHIGAN AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1432
Mailing Address - Country:US
Mailing Address - Phone:269-657-6025
Mailing Address - Fax:
Practice Address - Street 1:181 W MICHIGAN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1432
Practice Address - Country:US
Practice Address - Phone:269-657-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007699101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor