Provider Demographics
NPI:1093102048
Name:TAYLOR-EDWARDS, MARISA (MA,ATC)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:TAYLOR-EDWARDS
Suffix:
Gender:F
Credentials:MA,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 S ARDILLA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2407
Mailing Address - Country:US
Mailing Address - Phone:626-806-2127
Mailing Address - Fax:
Practice Address - Street 1:1409 S ARDILLA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2407
Practice Address - Country:US
Practice Address - Phone:626-806-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0201020132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer