Provider Demographics
NPI:1093905556
Name:TAYLOR, SIMONE (PSYD)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ADELINE ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2576
Mailing Address - Country:US
Mailing Address - Phone:510-848-1112
Mailing Address - Fax:510-848-4445
Practice Address - Street 1:3075 ADELINE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2576
Practice Address - Country:US
Practice Address - Phone:510-848-1112
Practice Address - Fax:510-848-4445
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS2005234103TF0000X
CA23552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01CROtherMEDI-CAL