Provider Demographics
NPI:1336649979
Name:TAYLOR, MARY THERESE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY THERESE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:EASTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23347-0294
Mailing Address - Country:US
Mailing Address - Phone:757-331-2712
Mailing Address - Fax:
Practice Address - Street 1:4208 SEASIDE RD
Practice Address - Street 2:
Practice Address - City:EXMORE
Practice Address - State:VA
Practice Address - Zip Code:23350-2575
Practice Address - Country:US
Practice Address - Phone:757-678-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist