Provider Demographics
NPI:1093279804
Name:PATRICK TAYLOR, TARA (BS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PATRICK TAYLOR
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-0623
Mailing Address - Country:US
Mailing Address - Phone:862-763-6648
Mailing Address - Fax:
Practice Address - Street 1:109 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-5869
Practice Address - Country:US
Practice Address - Phone:862-763-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ99988OtherMEDICAID/HEALTH CARE/
NJ999999OtherINSURANCE
NJ99999999Medicaid