Provider Demographics
NPI:1609839596
Name:TAYLOR, LEWIS JEROME III (PHD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:JEROME
Last Name:TAYLOR
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E LITTLE CREEK ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518
Mailing Address - Country:US
Mailing Address - Phone:757-587-4744
Mailing Address - Fax:757-587-4947
Practice Address - Street 1:1500 E LITTLE CREEK ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518
Practice Address - Country:US
Practice Address - Phone:757-587-4744
Practice Address - Fax:757-587-4947
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA279379OtherBCBS
VA007746393Medicaid
R60359Medicare UPIN