Provider Demographics
NPI:1063544005
Name:SCOTT, REGINA ANN (OTRL)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ANN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 HOLLY GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:BRAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:39044-2963
Mailing Address - Country:US
Mailing Address - Phone:601-847-0430
Mailing Address - Fax:
Practice Address - Street 1:260 BARNES RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-8066
Practice Address - Country:US
Practice Address - Phone:601-845-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02759579Medicaid