Provider Demographics
NPI:1629528427
Name:TAYLOR, EBONEE (LMT)
Entity Type:Individual
Prefix:
First Name:EBONEE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W ROBINHOOD DR
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5624
Mailing Address - Country:US
Mailing Address - Phone:209-910-0226
Mailing Address - Fax:
Practice Address - Street 1:1150 W ROBINHOOD DR
Practice Address - Street 2:SUITE 5A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5624
Practice Address - Country:US
Practice Address - Phone:209-910-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist