Provider Demographics
NPI:1962170779
Name:TAYLOR, TANEKA
Entity type:Individual
Prefix:MRS
First Name:TANEKA
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 1:2501 CHATHAM RD STE 5105
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:773-741-9440
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD STE 5105
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:773-741-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2022-02-07
Deactivation Date:2021-12-05
Deactivation Code:
Reactivation Date:2022-01-11
Provider Licenses
StateLicense IDTaxonomies
IL149.023462101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health