Provider Demographics
NPI:1194023168
Name:TAYLOR, KIM VICATORIA (LCAS)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:VICATORIA
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CAMBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4717
Mailing Address - Country:US
Mailing Address - Phone:919-989-8114
Mailing Address - Fax:919-938-0503
Practice Address - Street 1:109 CAMBRIDGE PL
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4717
Practice Address - Country:US
Practice Address - Phone:919-989-8114
Practice Address - Fax:919-938-0503
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP-0059601041C0700X
NC1774101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical