Provider Demographics
NPI:1538676705
Name:TAYLOR, JOHNNY WILLIE JR
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:WILLIE
Last Name:TAYLOR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MACOMBS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-2016
Mailing Address - Country:US
Mailing Address - Phone:718-299-3300
Mailing Address - Fax:
Practice Address - Street 1:1600 MACOMBS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-2016
Practice Address - Country:US
Practice Address - Phone:718-299-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24840101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1093883720Medicaid