Provider Demographics
NPI:1083490890
Name:TAYLOR, MICHELE SUSONWHA (RMP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SUSONWHA
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:RMP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:SUSONWHA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:5118 E JOPPA RD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9316
Mailing Address - Country:US
Mailing Address - Phone:805-758-0503
Mailing Address - Fax:
Practice Address - Street 1:260 GATEWAY DR STE 5A
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4266
Practice Address - Country:US
Practice Address - Phone:443-703-9815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR0888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist