Provider Demographics
NPI:1518664671
Name:TAYLOR, EBONY SUMAE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:SUMAE
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 1:2261 S WATNEY WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6757
Mailing Address - Country:US
Mailing Address - Phone:707-980-4581
Mailing Address - Fax:
Practice Address - Street 1:2261 S WATNEY WAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6757
Practice Address - Country:US
Practice Address - Phone:707-980-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker