Provider Demographics
NPI:1568531093
Name:TAYLOR, GRATIANA WILSON (LPC)
Entity Type:Individual
Prefix:MRS
First Name:GRATIANA
Middle Name:WILSON
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1990 EAGLE RIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3377
Mailing Address - Country:US
Mailing Address - Phone:678-712-1948
Mailing Address - Fax:
Practice Address - Street 1:110 EAGLE SPRING DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6488
Practice Address - Country:US
Practice Address - Phone:678-712-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006127101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional