Provider Demographics
NPI:1285300533
Name:TAYLOR, MICAH JOHN (ATC)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JOHN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:48 PURDY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-5053
Mailing Address - Country:US
Mailing Address - Phone:914-215-2425
Mailing Address - Fax:
Practice Address - Street 1:434 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-6410
Practice Address - Country:US
Practice Address - Phone:914-632-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004178-012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer