Provider Demographics
NPI:1932416633
Name:SCOTT, NICOLE K
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
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 1:714 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6410
Mailing Address - Country:US
Mailing Address - Phone:530-477-9800
Mailing Address - Fax:
Practice Address - Street 1:714 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6410
Practice Address - Country:US
Practice Address - Phone:530-477-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X, 101YM0800X, 1041C0700X
CAASW 65336104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW65336OtherBOARD OF BEHAVIORAL SCIENCES