Provider Demographics
NPI:1235469719
Name:TAYLOR, CHARESE (LMFT)
Entity Type:Individual
Prefix:
First Name:CHARESE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 NE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-6872
Mailing Address - Country:US
Mailing Address - Phone:502-224-2082
Mailing Address - Fax:239-354-1467
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:502-224-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY69561041C0700X
KY0818106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1265598270Medicaid
KY1033275342Medicaid
KY61-0471572Medicaid
KY1740554864Medicaid
KY1558591669Medicaid
KY1477618718Medicaid