Provider Demographics
NPI:1235921107
Name:ANDERSEN, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1087 STARK RD APT 5C
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 5327
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762-5327
Practice Address - Country:US
Practice Address - Phone:402-541-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer