Provider Demographics
NPI:1194374678
Name:HANES, TAYLOR MACKENZIE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MACKENZIE
Last Name:HANES
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 1:63 RIVER CREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-2542
Mailing Address - Country:US
Mailing Address - Phone:860-857-9009
Mailing Address - Fax:
Practice Address - Street 1:63 RIVER CREST DRIVE
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-2542
Practice Address - Country:US
Practice Address - Phone:860-857-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program