Provider Demographics
NPI:1609231463
Name:TAYLOR, DWAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
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 1:5414 BIFFLE WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088
Mailing Address - Country:US
Mailing Address - Phone:404-944-2056
Mailing Address - Fax:
Practice Address - Street 1:4328 RUSHMORE PL
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-1024
Practice Address - Country:US
Practice Address - Phone:404-666-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006933104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1609231463Medicaid