Provider Demographics
NPI:1992474753
Name:BLACK, TAYLOR (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 TECHNOLOGY DR UNIT 51
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6970
Mailing Address - Country:US
Mailing Address - Phone:760-695-2899
Mailing Address - Fax:
Practice Address - Street 1:1145 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1025
Practice Address - Country:US
Practice Address - Phone:207-541-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist