Provider Demographics
NPI:1992267371
Name:SCOTT, THERESA (LGSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN STE 198
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5339
Mailing Address - Country:US
Mailing Address - Phone:301-386-2991
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN STE 198
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5339
Practice Address - Country:US
Practice Address - Phone:301-386-2991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG13159104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG13159Medicaid