Provider Demographics
NPI:1174266985
Name:TAYLOR, CHARMION LYNELL
Entity Type:Individual
Prefix:
First Name:CHARMION
Middle Name:LYNELL
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 1:1017 FAYETTEVILLE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 LONGLEAF BLVD STE B
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8458
Practice Address - Country:US
Practice Address - Phone:678-376-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014101101YM0800X
GA006480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health