Provider Demographics
NPI:1083180848
Name:TAYLOR, BENJAMIN A
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 COSBY WAY DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-8288
Mailing Address - Country:US
Mailing Address - Phone:616-443-6853
Mailing Address - Fax:
Practice Address - Street 1:5242 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1084
Practice Address - Country:US
Practice Address - Phone:616-443-6853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016786101Y00000X, 101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor