Provider Demographics
NPI:1467002485
Name:CHIATALAS, TAYLOR M (DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:M
Last Name:CHIATALAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:M
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22180 PONTIAC TRAIL
Mailing Address - Street 2:SUITE E
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9097
Mailing Address - Country:US
Mailing Address - Phone:248-446-0155
Mailing Address - Fax:248-446-0177
Practice Address - Street 1:22180 PONTIAC TRAIL
Practice Address - Street 2:SUITE E
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9097
Practice Address - Country:US
Practice Address - Phone:248-446-0155
Practice Address - Fax:248-446-0177
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist