Provider Demographics
NPI:1407098841
Name:TAYLOR, MARCELLUS O (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARCELLUS
Middle Name:O
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4428 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3405
Mailing Address - Country:US
Mailing Address - Phone:850-209-2643
Mailing Address - Fax:
Practice Address - Street 1:2998 VORTEC RD
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-6734
Practice Address - Country:US
Practice Address - Phone:850-209-2643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59690OtherBCBS
FL59690Medicare PIN