Provider Demographics
NPI:1184199853
Name:TAYLOR, OLIVER RAKEEM
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:RAKEEM
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5514
Mailing Address - Country:US
Mailing Address - Phone:619-977-3716
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5514
Practice Address - Country:US
Practice Address - Phone:619-977-3716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist