Provider Demographics
NPI:1275369548
Name:TAYLOR, KESIA
Entity type:Individual
Prefix:
First Name:KESIA
Middle Name:
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 1:2101 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-3062
Mailing Address - Country:US
Mailing Address - Phone:219-356-1902
Mailing Address - Fax:
Practice Address - Street 1:530 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-3439
Practice Address - Country:US
Practice Address - Phone:708-868-7926
Practice Address - Fax:708-868-7671
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2054062103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool