Provider Demographics
NPI:1679272090
Name:SCOTT, FRED RANDOLPH III
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:RANDOLPH
Last Name:SCOTT
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-1492
Mailing Address - Country:US
Mailing Address - Phone:757-269-1400
Mailing Address - Fax:757-809-3423
Practice Address - Street 1:208 REPUBLIC LN
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-1005
Practice Address - Country:US
Practice Address - Phone:757-269-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013358101YP2500X
VA0701012670101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional