Provider Demographics
NPI:1326878836
Name:TAYLOR, KATHLEEN MARIE (LLMSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26480 BERG RD APT 1220
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-8615
Mailing Address - Country:US
Mailing Address - Phone:580-656-5872
Mailing Address - Fax:
Practice Address - Street 1:5980 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2377
Practice Address - Country:US
Practice Address - Phone:248-625-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851118549104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
16286277OtherCAQH
TAYLORK1968OtherCHAMPS