Provider Demographics
NPI:1528475225
Name:TAYLOR, THERESSA ROSE (LAC, CRC)
Entity type:Individual
Prefix:MRS
First Name:THERESSA
Middle Name:ROSE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LAC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2816
Mailing Address - Country:US
Mailing Address - Phone:870-647-1400
Mailing Address - Fax:
Practice Address - Street 1:1310 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2816
Practice Address - Country:US
Practice Address - Phone:870-647-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1407092101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health