Provider Demographics
NPI:1437652005
Name:BLACK, TAYLOR R (AUD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-638-2515
Mailing Address - Fax:252-638-8538
Practice Address - Street 1:3110 WELLONS BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5247
Practice Address - Country:US
Practice Address - Phone:252-638-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
NC231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473275Medicaid