Provider Demographics
NPI:1407291164
Name:THOMAS, TAYLOR L
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:L
Last Name:THOMAS
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 1:1156 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5931
Mailing Address - Country:US
Mailing Address - Phone:805-748-5748
Mailing Address - Fax:
Practice Address - Street 1:17350 MOUNT HERRMANN ST
Practice Address - Street 2:SUITE A
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4114
Practice Address - Country:US
Practice Address - Phone:714-444-3463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical