Provider Demographics
NPI:1376062026
Name:TAYLOR, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 BOAT CLUB ROAD
Mailing Address - Street 2:SUITE 240 # 239
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-7734
Mailing Address - Country:US
Mailing Address - Phone:817-269-4777
Mailing Address - Fax:
Practice Address - Street 1:8101 BOAT CLUB ROAD
Practice Address - Street 2:SUITE 240 # 239
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-7734
Practice Address - Country:US
Practice Address - Phone:817-269-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128682225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty