Provider Demographics
NPI:1972914661
Name:SCOTT, CARLY (LMP)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3006
Mailing Address - Country:US
Mailing Address - Phone:360-909-9341
Mailing Address - Fax:
Practice Address - Street 1:1146 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3025
Practice Address - Country:US
Practice Address - Phone:360-577-6956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60331034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist