Provider Demographics
NPI:1306403852
Name:PINKHAM, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:PINKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:POTRZEBOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:507 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3201
Mailing Address - Country:US
Mailing Address - Phone:309-686-1177
Mailing Address - Fax:309-686-7722
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:309-686-7722
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-19-105973106S00000X
1-22-60334103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician