Provider Demographics
NPI:1457527764
Name:FENTON, SCOTT L (PSYD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
Last Name:FENTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 MONONA DR STE 408
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3561
Mailing Address - Country:US
Mailing Address - Phone:608-628-3963
Mailing Address - Fax:608-501-0978
Practice Address - Street 1:5900 MONONA DR STE 408
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3561
Practice Address - Country:US
Practice Address - Phone:608-628-3963
Practice Address - Fax:608-501-0978
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2531057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical