Provider Demographics
NPI:1346378155
Name:TAYLOR, HEATHER B (MFT)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 FREDRICKS RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-5643
Mailing Address - Country:US
Mailing Address - Phone:707-829-5525
Mailing Address - Fax:
Practice Address - Street 1:625 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4202
Practice Address - Country:US
Practice Address - Phone:707-547-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA64-0950423OtherTAX ID