Provider Demographics
NPI:1194087296
Name:SCOTT, ELAINE SUSANNE (MED)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:SUSANNE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 ROCKWOOD LN
Mailing Address - Street 2:APT 129
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-8064
Mailing Address - Country:US
Mailing Address - Phone:512-921-1717
Mailing Address - Fax:
Practice Address - Street 1:4024 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2409
Practice Address - Country:US
Practice Address - Phone:718-984-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY707038174400000X
NY1271067174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist