Provider Demographics
NPI:1467008755
Name:HEEDLES, TAYLOR AMABILE
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:AMABILE
Last Name:HEEDLES
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 1:16019 80TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2918
Mailing Address - Country:US
Mailing Address - Phone:718-775-1541
Mailing Address - Fax:
Practice Address - Street 1:321 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-2035
Practice Address - Country:US
Practice Address - Phone:516-295-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No252Y00000XAgenciesEarly Intervention Provider Agency