Basic Information
| Provider Information | |||||||||
| NPI: | 1538336987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT-GRANT | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE # MS 958 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7322 W RAWSON AVE | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531328117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142284800 | ||||||||
| FaxNumber: | 4144339007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6904-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1538336987 | 05 | WI | MEDICAID |