Provider Demographics
NPI:1285440529
Name:SCOTT, GARY A SR (PASTOR)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:A
Last Name:SCOTT
Suffix:SR
Gender:M
Credentials:PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15411 W WADDELL RD STE 102-128
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5170
Mailing Address - Country:US
Mailing Address - Phone:480-613-7677
Mailing Address - Fax:
Practice Address - Street 1:6551 S 43RD LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-6246
Practice Address - Country:US
Practice Address - Phone:480-613-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD514871744R1102X, 374K00000X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No1744R1102XOther Service ProvidersSpecialistResearch Study
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner