Provider Demographics
NPI:1962571349
Name:TAYLOR, KATHLEEN A (LPCP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LPCP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPCP, LSW
Mailing Address - Street 1:496 A ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3617
Mailing Address - Country:US
Mailing Address - Phone:208-552-7100
Mailing Address - Fax:208-552-7101
Practice Address - Street 1:496 A ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3617
Practice Address - Country:US
Practice Address - Phone:208-552-7100
Practice Address - Fax:208-552-7101
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-199101YM0800X
IDLSW-5581041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378585Medicare ID - Type UnspecifiedCLINIC NUMBER