Provider Demographics
NPI:1184003923
Name:TAYLOR, BRENDA (LMSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8025
Mailing Address - Country:US
Mailing Address - Phone:208-542-9919
Mailing Address - Fax:
Practice Address - Street 1:2100 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8025
Practice Address - Country:US
Practice Address - Phone:208-542-9919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33104101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor