Provider Demographics
NPI:1477125573
Name:TAYLOR, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TAYLOR
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 1:946 E KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2314
Mailing Address - Country:US
Mailing Address - Phone:530-638-2013
Mailing Address - Fax:
Practice Address - Street 1:170 S 1000 E STE 201
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1403
Practice Address - Country:US
Practice Address - Phone:801-419-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12076743-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty