Provider Demographics
NPI:1104586940
Name:TAYLOR, LORETTA DEE
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:DEE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 PROFESSIONAL PARK DR SE STE 10
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6649
Mailing Address - Country:US
Mailing Address - Phone:540-605-8751
Mailing Address - Fax:
Practice Address - Street 1:210 PROFESSIONAL PARK DR SE STE 10
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6649
Practice Address - Country:US
Practice Address - Phone:540-605-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017139225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083950406OtherWORKERS COMPENSATION