Provider Demographics
NPI:1659497964
Name:SCOTT, KENNETH C (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:SCOTT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2344
Mailing Address - Country:US
Mailing Address - Phone:310-569-8321
Mailing Address - Fax:310-829-7868
Practice Address - Street 1:3201 WILSHIRE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-2344
Practice Address - Country:US
Practice Address - Phone:310-569-8321
Practice Address - Fax:310-829-7868
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18087103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18087Medicare ID - Type UnspecifiedPSYCHOLOGIST