Provider Demographics
NPI:1457923153
Name:TAYLOR, SHANEN
Entity type:Individual
Prefix:
First Name:SHANEN
Middle Name:
Last Name:TAYLOR
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 1:304 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1825
Mailing Address - Country:US
Mailing Address - Phone:712-527-2823
Mailing Address - Fax:712-527-4193
Practice Address - Street 1:304 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1825
Practice Address - Country:US
Practice Address - Phone:712-527-2823
Practice Address - Fax:712-527-4193
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA109464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA109464OtherLICENSURE