Provider Demographics
NPI:1538865902
Name:SCOTT, BROOKE CANNON (LAC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:CANNON
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 SE 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2225
Mailing Address - Country:US
Mailing Address - Phone:410-971-6031
Mailing Address - Fax:
Practice Address - Street 1:2330 NW FLANDERS ST STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3400
Practice Address - Country:US
Practice Address - Phone:876-701-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC214231171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist