Provider Demographics
NPI:1669434445
Name:ELKERTON, SCOTT CHARLES (LICSW)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHARLES
Last Name:ELKERTON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 COON RAPIDS BLVD NW
Mailing Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4708
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN897104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN473R5ELOtherBCBS
HP21707OtherHEALTH PARTNERS
115670OtherUCARE
6252842OtherUBH
MN1013103OtherPREFERRED ONE
MN949318200Medicaid
MN800001594Medicare ID - Type Unspecified