Provider Demographics
NPI:1306355292
Name:TAYLOR, BENETA HELENA
Entity type:Individual
Prefix:
First Name:BENETA
Middle Name:HELENA
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 1:19673 HARNED ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1508
Mailing Address - Country:US
Mailing Address - Phone:313-398-7798
Mailing Address - Fax:
Practice Address - Street 1:356 E GRAND BLVD APT 404
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3661
Practice Address - Country:US
Practice Address - Phone:313-398-7798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-24
Last Update Date:2017-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI46-5496216OtherHEALTH INSURANCE
MI46-5496216Medicaid