Provider Demographics
NPI:1427602978
Name:TAYLOR, ALICIA KEESHAN (MT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:KEESHAN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 GUNBOAT DR UNIT 31
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907
Mailing Address - Country:US
Mailing Address - Phone:254-317-5013
Mailing Address - Fax:
Practice Address - Street 1:5401 GUNBOAT DR UNIT 31
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907
Practice Address - Country:US
Practice Address - Phone:254-317-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004465225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPI-ABMP-19OtherABMP ALLIED PROFESSIONALS INSURANCE