Provider Demographics
NPI:1326220419
Name:TAYLOR, EDDIE RENARD
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:RENARD
Last Name:TAYLOR
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 1:6744 CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2287
Mailing Address - Country:US
Mailing Address - Phone:818-760-9469
Mailing Address - Fax:
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068OtherUPIN MEDICARE MEDICAID
CA7068OtherOUTPATIENT MENTALHEALTH
CA7068OtherUPIN
CA7068Medicaid
CA7068Medicare UPIN