Provider Demographics
NPI:1194768655
Name:SCOTT, CARL BRENT (PT)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:BRENT
Last Name:SCOTT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 PINEHURST CT.
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434
Mailing Address - Country:US
Mailing Address - Phone:918-478-8249
Mailing Address - Fax:
Practice Address - Street 1:2021 MAHANEY AVE., STE. 6
Practice Address - Street 2:NORTHEASTERN PHYSICAL REHAB
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-458-5115
Practice Address - Fax:918-458-5119
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK650020254OtherRR MEDICARE
OK100834890AMedicaid
OKA002OtherTRICARE
OK175254900OtherDEPT OF LABOR
OK$$$$$$$$$001OtherBCBS
OK650020254OtherRR MEDICARE