Provider Demographics
NPI:1336861095
Name:TAYLOR, DAWAYNE
Entity type:Individual
Prefix:
First Name:DAWAYNE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E FRANKLIN ST STE 710
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-2511
Mailing Address - Country:US
Mailing Address - Phone:804-551-4158
Mailing Address - Fax:
Practice Address - Street 1:4245 N CENTRAL EXPY STE 490
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-4231
Practice Address - Country:US
Practice Address - Phone:804-551-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251B00000X, 261QM0801X, 251S00000X
251B00000X, 251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)