Provider Demographics
NPI:1306579529
Name:TAYLOR, LAURIE (NONE)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 CHICAGO AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2209
Mailing Address - Country:US
Mailing Address - Phone:951-357-6926
Mailing Address - Fax:
Practice Address - Street 1:13889 FREDERICK ST APT D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8668
Practice Address - Country:US
Practice Address - Phone:909-294-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CAAPCC13851101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician