Provider Demographics
NPI:1073743340
Name:SCOTT, DESIREE CAMILIA
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:CAMILIA
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 1:1556 FITZGERALD DR # 222
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2229
Mailing Address - Country:US
Mailing Address - Phone:415-254-6647
Mailing Address - Fax:
Practice Address - Street 1:1556 FITZGERALD DR # 222
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2229
Practice Address - Country:US
Practice Address - Phone:415-254-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA92512225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor