Provider Demographics
NPI:1437110657
Name:MANDEVILLE, SCOTT WESTON (LCSW, CSOTP)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:WESTON
Last Name:MANDEVILLE
Suffix:
Gender:M
Credentials:LCSW, CSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:VA
Mailing Address - Zip Code:22812-1124
Mailing Address - Country:US
Mailing Address - Phone:540-828-3663
Mailing Address - Fax:540-828-2322
Practice Address - Street 1:108 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1124
Practice Address - Country:US
Practice Address - Phone:540-828-3663
Practice Address - Fax:540-828-2322
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040029901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA462838OtherANTHEM
VA1891959169Medicaid
VA828523000OtherMAGELLAN
VA219164OtherCOM-PSYCH
VAO86454MOtherSENTARA
VAC09366Medicare ID - Type Unspecified
VA462838OtherANTHEM