Provider Demographics
NPI:1326394230
Name:TAYLOR, MATTIE LOR ROSE (ATC)
Entity Type:Individual
Prefix:MS
First Name:MATTIE LOR
Middle Name:ROSE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20696 ALDO CT
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-2400
Mailing Address - Country:US
Mailing Address - Phone:586-907-7087
Mailing Address - Fax:
Practice Address - Street 1:20696 ALDO CT
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-2400
Practice Address - Country:US
Practice Address - Phone:586-907-7087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer