Provider Demographics
NPI:1528565488
Name:TAYLOR, KENNETH JAMES (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N 7TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5796
Mailing Address - Country:US
Mailing Address - Phone:208-242-3044
Mailing Address - Fax:208-904-0494
Practice Address - Street 1:707 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5785
Practice Address - Country:US
Practice Address - Phone:208-242-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10046101YA0400X
ID37236104100000X
IDLCSW-422041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker