Provider Demographics
NPI:1235677725
Name:TAYLOR, EUGENIE PROVOSTY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:EUGENIE
Middle Name:PROVOSTY
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LEON SULLIVAN WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2402
Mailing Address - Country:US
Mailing Address - Phone:304-346-9689
Mailing Address - Fax:
Practice Address - Street 1:16 LEON SULLIVAN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2402
Practice Address - Country:US
Practice Address - Phone:304-346-9689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP00939976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health