Provider Demographics
NPI:1376665919
Name:TAYLOR, RAELEEN ELISE (BA)
Entity Type:Individual
Prefix:MS
First Name:RAELEEN
Middle Name:ELISE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5868 BRENTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-1118
Mailing Address - Country:US
Mailing Address - Phone:323-232-6527
Mailing Address - Fax:
Practice Address - Street 1:333 S BEAUDRY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1466
Practice Address - Country:US
Practice Address - Phone:213-741-3841
Practice Address - Fax:213-241-3305
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CA941241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner