Provider Demographics
NPI:1528341443
Name:SCOTT, SHANE M (LCSW)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LASALLE RD STE 401
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2319
Mailing Address - Country:US
Mailing Address - Phone:860-748-5390
Mailing Address - Fax:
Practice Address - Street 1:76 LASALLE RD STE 401
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2319
Practice Address - Country:US
Practice Address - Phone:860-748-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0096121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical