Provider Demographics
NPI:1417524547
Name:STOUDENMIER, TAYLOR MACKENZIE (LGC)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:MACKENZIE
Last Name:STOUDENMIER
Suffix:
Gender:
Credentials:LGC
Other - Prefix:MISS
Other - First Name:TAYLOR
Other - Middle Name:MACKENZIE
Other - Last Name:KUPNESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 QUEENS RD STE 560
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3580
Practice Address - Country:US
Practice Address - Phone:980-302-6270
Practice Address - Fax:980-302-6275
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20203170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
20203OtherAMERICAN BOARD OF GENETIC COUNSELING CERTIFICATE
FLGC46OtherGENETIC COUNSELOR STATE LICENSURE
SC20OtherGENETIC COUNSELOR STATE LICENSURE