Provider Demographics
NPI:1033763503
Name:HANCOCK, TAYLER
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:HANCOCK
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:PO BOX 11231
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1231
Mailing Address - Country:US
Mailing Address - Phone:804-614-5853
Mailing Address - Fax:
Practice Address - Street 1:310 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:804-614-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18-63956106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician