Provider Demographics
NPI:1083878110
Name:TAYLOR, GLENN A
Entity Type:Individual
Prefix:
First Name:GLENN
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 1:1231 SAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4846
Mailing Address - Country:US
Mailing Address - Phone:718-902-6137
Mailing Address - Fax:718-382-3358
Practice Address - Street 1:1670 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1258
Practice Address - Country:US
Practice Address - Phone:718-375-1200
Practice Address - Fax:718-382-3358
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health