Provider Demographics
NPI:1962125179
Name:TAYLOR, KENNETH OSCAR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:OSCAR
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 BUXTON RD
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-9511
Mailing Address - Country:US
Mailing Address - Phone:207-286-5489
Mailing Address - Fax:
Practice Address - Street 1:400 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1704
Practice Address - Country:US
Practice Address - Phone:120-777-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAD7993101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)