Provider Demographics
NPI:1114117009
Name:TAYLOR, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 SEMINOLE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-6600
Mailing Address - Country:US
Mailing Address - Phone:307-679-1822
Mailing Address - Fax:
Practice Address - Street 1:184 SEMINOLE DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-6600
Practice Address - Country:US
Practice Address - Phone:307-679-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-4231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical