Provider Demographics
NPI:1093896607
Name:DAWN O TAYLOR, PHD, PC
Entity Type:Organization
Organization Name:DAWN O TAYLOR, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERRITSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:303-499-2217
Mailing Address - Street 1:1062 LOVE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2975
Mailing Address - Country:US
Mailing Address - Phone:303-499-2217
Mailing Address - Fax:303-499-2217
Practice Address - Street 1:3445 PENROSE PL
Practice Address - Street 2:STE 250
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1878
Practice Address - Country:US
Practice Address - Phone:303-473-4435
Practice Address - Fax:303-447-6453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO731103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07007313Medicaid
COC88966Medicare PIN