1205951449 NPI number — MRS. GWENDOLYN TAYLOR SCOTT MSW

Table of content: MS. COURTNEY PELLETIER LICSW (NPI 1861636193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205951449 NPI number — MRS. GWENDOLYN TAYLOR SCOTT MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
GWENDOLYN
Provider Middle Name:
TAYLOR
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205951449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5310 YADKIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28303-3255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-491-5164
Provider Business Mailing Address Fax Number:
910-229-3227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5860 YADKIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28303-2668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-491-5164
Provider Business Practice Location Address Fax Number:
910-229-3227
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C001347 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13855 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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