Provider Demographics
NPI:1194893453
Name:HENDRICKSON, SCOTT ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERT
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 S RURAL RD STE 111
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3717
Mailing Address - Country:US
Mailing Address - Phone:480-345-9888
Mailing Address - Fax:480-345-2126
Practice Address - Street 1:6625 S RURAL RD STE 111
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3717
Practice Address - Country:US
Practice Address - Phone:480-345-9888
Practice Address - Fax:480-345-2126
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ962103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0135130OtherBLUECROSSBLUESHIELD
AZ0135130OtherBLUECROSSBLUESHIELD