Provider Demographics
NPI:1205487162
Name:SCOTT, MAURICE ANTOINE
Entity type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:ANTOINE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 CLONMEL PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2502
Mailing Address - Country:US
Mailing Address - Phone:704-618-1004
Mailing Address - Fax:
Practice Address - Street 1:3705 LATROBE DR STE 340
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4823
Practice Address - Country:US
Practice Address - Phone:704-618-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20806101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty