Provider Demographics
NPI:1114408291
Name:TAYLOR, GREGORY (EDUCATOR)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN STE 129-10
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:240-462-7983
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN STE 129-10
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:240-462-7983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
MD174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator