Provider Demographics
NPI:1487182606
Name:TAYLOR, OWEN RUSSELL
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:RUSSELL
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
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 10844
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-0844
Mailing Address - Country:US
Mailing Address - Phone:216-391-0977
Mailing Address - Fax:216-391-0978
Practice Address - Street 1:3030 EUCLID AVE STE 312
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2518
Practice Address - Country:US
Practice Address - Phone:216-391-0977
Practice Address - Fax:216-391-0978
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH923209101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)