Provider Demographics
NPI:1871605915
Name:SCOTT, CEDRIC HARLAN (LIMITED LICENSE PSYC)
Entity type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:HARLAN
Last Name:SCOTT
Suffix:
Gender:M
Credentials:LIMITED LICENSE PSYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 BAKER ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-733-6607
Mailing Address - Fax:231-737-0534
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-733-6607
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012964103T00000X
MI200727103TA0400X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231858Medicare Oscar/Certification