Provider Demographics
NPI:1497530497
Name:TAYLOR, KIMBERLA
Entity Type:Individual
Prefix:
First Name:KIMBERLA
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 1:3730 MEETING ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3182
Mailing Address - Country:US
Mailing Address - Phone:404-692-9416
Mailing Address - Fax:
Practice Address - Street 1:772 SMOKEY RD
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:GA
Practice Address - Zip Code:30630-2338
Practice Address - Country:US
Practice Address - Phone:404-692-9416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA740785405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional