Provider Demographics
NPI:1386606143
Name:TAYLOR, CONSTANCE MARIE (PHD)
Entity type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E. OLIVE AVENUE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5268
Mailing Address - Country:US
Mailing Address - Phone:909-798-7711
Mailing Address - Fax:909-798-5188
Practice Address - Street 1:222 E. OLIVE AVENUE
Practice Address - Street 2:SUITE 7
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5268
Practice Address - Country:US
Practice Address - Phone:909-798-7711
Practice Address - Fax:909-798-5188
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2012-03-01
Deactivation Date:2009-09-10
Deactivation Code:
Reactivation Date:2012-02-27
Provider Licenses
StateLicense IDTaxonomies
CA9649103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPL186680Medicare PIN
OPL186680Medicare UPIN