Provider Demographics
NPI:1063632081
Name:TAYLOR, MISTYLEE B (SLP)
Entity Type:Individual
Prefix:
First Name:MISTYLEE
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 KITTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9576
Mailing Address - Country:US
Mailing Address - Phone:260-338-1241
Mailing Address - Fax:
Practice Address - Street 1:808 MILL LAKE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-6400
Practice Address - Country:US
Practice Address - Phone:260-338-1241
Practice Address - Fax:260-338-1231
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004150A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist