Provider Demographics
NPI:1588339477
Name:TAYLOR, MERCEDES NICHOLE
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:NICHOLE
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 1:12980 MORRIS STEEN RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32331-8678
Mailing Address - Country:US
Mailing Address - Phone:850-843-5351
Mailing Address - Fax:
Practice Address - Street 1:5447 E BEAUMONT CENTER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5210
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-20-109630106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty