Provider Demographics
NPI:1508632779
Name:EDWARDS, TAYLOR BLAKE (LCDC)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BLAKE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 ABBEY FIELD LN
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-8514
Mailing Address - Country:US
Mailing Address - Phone:903-754-3457
Mailing Address - Fax:
Practice Address - Street 1:904 FM 686
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2299
Practice Address - Country:US
Practice Address - Phone:936-257-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16715101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)