Provider Demographics
NPI:1508355769
Name:LIGHTFOOT, TAYLOR ALEXIS
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ALEXIS
Last Name:LIGHTFOOT
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 1:14287 WINDING VALLEY RD N
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-7218
Mailing Address - Country:US
Mailing Address - Phone:901-314-5992
Mailing Address - Fax:
Practice Address - Street 1:6761 STAGE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3867
Practice Address - Country:US
Practice Address - Phone:901-379-8827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-17-28786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician