Provider Demographics
NPI:1053062604
Name:VICK, TAYLOR LYNN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LYNN
Last Name:VICK
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 1:26900 WINCHESTER CREEK AVE APT 1307
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4103
Mailing Address - Country:US
Mailing Address - Phone:763-234-1318
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST STE 1030
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5085
Practice Address - Country:US
Practice Address - Phone:877-206-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty