Provider Demographics
NPI:1093185795
Name:SELF, TAYLOR NICOLE (LCSWA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:SELF
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 W MAIN ST
Mailing Address - Street 2:SUITE 132
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-3076
Mailing Address - Country:US
Mailing Address - Phone:828-429-9906
Mailing Address - Fax:704-487-4005
Practice Address - Street 1:179 W MAIN ST
Practice Address - Street 2:SUITE 132
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3076
Practice Address - Country:US
Practice Address - Phone:828-248-4403
Practice Address - Fax:704-487-4005
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0100891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical