Provider Demographics
NPI:1295200194
Name:SOUTH, TAYLOR
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:
Last Name:SOUTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 MIRIAM ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3720
Mailing Address - Country:US
Mailing Address - Phone:602-819-8776
Mailing Address - Fax:
Practice Address - Street 1:2802 MIRIAM ST S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33711-3720
Practice Address - Country:US
Practice Address - Phone:602-819-8776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
FLMT3930106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist