Provider Demographics
NPI:1093345167
Name:TAYLOR, DANA SHANTEL (LCSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:SHANTEL
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1206
Mailing Address - Country:US
Mailing Address - Phone:618-847-8362
Mailing Address - Fax:
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1206
Practice Address - Country:US
Practice Address - Phone:618-847-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0122301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical