Provider Demographics
NPI:1326611229
Name:SMITH, TAYLOR B
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:B
Last Name:SMITH
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 1:78 EVANS LN NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-3724
Mailing Address - Country:US
Mailing Address - Phone:512-915-9177
Mailing Address - Fax:
Practice Address - Street 1:5342 10TH ARMORED LOOP
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-7089
Practice Address - Country:US
Practice Address - Phone:512-915-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician