Provider Demographics
NPI:1205184827
Name:TAYLOR, TRACY LYNN (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5026
Mailing Address - Country:US
Mailing Address - Phone:417-781-3616
Mailing Address - Fax:417-782-1490
Practice Address - Street 1:1211 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5026
Practice Address - Country:US
Practice Address - Phone:417-781-3616
Practice Address - Fax:417-782-1490
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012015600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst